International Trends: New challenges to reproductive health and rights within the framework of the Millennium Development Goals

I’m very happy to be speaking to all of you at this important event today. Before beginning, I would like to congratulate the Inter-Institutional Group on Reproductive Health on its ten years of existence and the effective collaboration they have successfully established between the government and civil society in an area that is truly in need this kind of dialogue. Fortunately, you have many lessons to share with other countries, particularly those in which the government has not yet recognized the importance of civil society, or in which civil society organizations refuse to collaborate with their governments for fear of losing their independence and ability to take bold measures. You also have lessons to offer to countries in which civil society has actually lost its independence as a result of collaborating too closely with the government. The Inter-Institutional Group has the great virtue of knowing how to keep each party’s role separate while continuing support, constructively critique, and mutually respect each other.

I would also like to congratulate you on the importance and relevance of the topics we’ll be addressing in the next few days. As you know, the issue of sexual and reproductive health has become particularly significant in Mexico since the last election. Within this context of transitioning to a new government, it is crucial that every effort is made to consolidate the advances made over the past several years in the field of sexual and reproductive health and rights.

Maybe some of you remember when I participated in the Third National Conference on Risk-Free Maternity in Mexico three years ago. At the time, I referred to an issue that was particularly worrisome to me. I referred to the risk of retreating in light of the assault by conservative and fundamental influences. This concern is, of course, still as valid now as it was then.

I am also celebrating the fact that we are discussing these issues precisely today. As you know, last week was extremely important to all of us working in this field. The results of the U.S. legislative elections have opened up the possibility of placing limits on the excesses of the Bush administration. Last week, too, the panel appointed by Kofi Annan to develop recommendations for reforming the United Nations system approved the proposal presented by women’s organizations to create a new entity within the UN that will have the power needed to implement policies to promote women’s rights. This is an area that has been historically relegated, despite the advances made at the Beijing Conference. Additionally, here in the Federal District, the law on co-habitation was passed last week, making Mexico the third Latin American country to recognize equal rights for gay and lesbian couples. Meanwhile, in a less encouraging development, the Nicaraguan Legislative Assembly approved a law eliminating access to therapeutic abortion, sounding a very serious warning on the risk we continue to face in our region of moving backwards.

Therefore, I’m addressing you all today with concern, but also full of hope. Concern because of the electioneering and opportunist interests that continue to prevail over women’s needs and lives. Concern because progressive forces have still not been capable of articulating an effective strategy to reach the majority of the population with a clear and convincing message on the importance of maintaining a secular state. Concern because people in the poorest sectors of our societies continue to live as second-class citizens, without the respect due to their most basic human rights, including their sexual and reproductive rights. Concern because, as was noted in a recent issue of The Lancet, the WHO has warned that unprotected sex continues to be the second greatest risk factor for morbidity and mortality in the world’s poorest countries, while violence during pregnancy continues to be more common than issues that receive more attention, such as hypertension and pre-eclampsia. 

But I’m also full of hope. Hope because there is now a large number of people committed to human rights, social justice, and women’s empowerment. Hope because there is currently much research underway that will help to develop public policies enabling the fulfillment of all people’s needs. Hope because men and women, young and not so young, are changing their everyday behaviors, building more equal and pleasurable relationships.
 
I have been asked to speak about the existing challenges to realizing the promise of reproductive health and rights within the framework of the Millennium Development Goals. As you know, the Goals were approved in Monterrey in 2000 by all United Nations Member States and therefore represent an internationally accepted platform for development. The Goals embody a qualitative step forward from previous initiatives, as they include three advantages I consider key. First, they have the political endorsement of a great number of nations; second, they are extremely concrete and functional, including eight goals that break down into quantifiable objectives within clear periods of implementation; and third, they are feasible.

The Millennium Goals have the great benefit of offering a general development plan that assigns concrete responsibilities to the international community and individual countries. In addition, they have the advantage of being a potential tool for civil society to monitor governments’ actions and demand concrete results in the area of development.

However, despite all of these assets, many of us deeply regret that the Goals do not include sexual and reproductive health among their basic premises, a very serious mistake that threatens their ultimate objective. Sexual and reproductive rights language is invisible in the goals, a conspicuous oversight in light of the wide exposure this language has had through the Cairo and Beijing conferences. Given this omission, it is worth asking: is it possible to reach the Goals without taking into account the lessons and principles offered by these two international conferences? Is it possible to reach the Goals without considering sexual and reproductive rights? The answer is an emphatic “no.”

With the aim of rectifying this omission and of once again placing sexual and reproductive rights within the international development agenda, my organization, the International Planned Parenthood Federation, coordinated efforts with other members of civil society and UN agencies.  In August 2005, we organized a sub-regional forum in Brasilia in collaboration with the Brazilian government, the United Nations Population Fund, UNAIDS, and UNIFEM, which included the participation of ministers, parliamentarians, government officials, and members of civil society from 9 countries in the region. The forum unanimously approved a declaration urging Latin American and Caribbean governments to uphold a common regional position at the 2005 World Summit and to emphasize the importance of including sexual and reproductive health in reaching the Goals.

Fortunately, this and other initiatives seem to have taken effect. The Summit’s outcome document explicitly mentions the need to support universal access to reproductive health by the year 2015.

More recently, last October, the Secretary General of the United Nations presented a report to the General Assembly that noted the results of the summit, recommending the inclusion of a new objective on achieving universal access to reproductive health by 2015. This is an important step in the right direction.

The arduous battle we have waged to include sexual and reproductive health in the Goals has begun to bear fruit, despite the difficult obstacles we have had to face and overcome through this journey. As you all may remember, the U.S. government, with the support of religious fundamentalists from several countries, did all it could to oppose this inclusion. But it failed largely because of the efforts of those of us concerned with the well-being and progress of humanity. We must celebrate this triumph, this victory of David against Goliath.

And now what? We must not become complacent. We must not rest on our laurels, we must progress, and continue to face the obstacles that still keep us from ensuring all people’s access to sexual and reproductive health. For this reason, I would like to discuss five concrete obstacles that have a particularly strong impact on our region.

I’ll start with the issue of inequality. As you all know, Latin America has the sad distinction of being the most unequal region in the world. Although in terms of income we may be richer than other regions, in terms of inequality we are the lowest ranked, including below Africa.

The disparity in income between rich and poor is simply appalling. A recent report by the Economic Commission for Latin American and the Caribbean notes that in Latin America, the richest fifth of society receives between 42% (Uruguay) and 62% (Brazil) of the total income, while the 20% representing the poorest households receives between 2% (Bolivia) and 9% (Uruguay) of the total income. This obscene inequality is at the root of many of the problems affecting our region.

But economic inequality is not only harmful in itself, it is also self-perpetuating and hinders the fight against poverty. Several studies clearly show that children from poor households have very limited access to the most basic social services, including health and education. As a result, children of the poor end up with very low chances at finding quality employment and remain in an unstable position throughout their adult life, continuing the vicious circle of poverty. The lack of opportunities is passed on in an almost hereditary manner: poor parents have poor children and poor grandchildren.

Naturally, inequality in income manifests and impacts on all areas of life. Health is a clear example of this fact. The Inter-American Development Bank shows that there is a strong correlation between inequality in income distribution and inequality in access to health services. Sexual and reproductive health is no exception to this fact. Let me show you a chart that illustrates inequality in professionally attended births in the richest and poorest sectors. (Slide 1). Here we see that in all of these countries the level of inequality is extremely acute.

This inequality produces very serious consequences, including restricting the right to life of the poorest women. Every year, between 20 and 25 thousand women die in Latin America as a result of complications during pregnancy. Some of our countries and areas have mortality levels approaching those of sub-Saharan Africa, which are the highest in the world. Haiti has the highest level, with 600 maternal deaths for every 100,000 live births. This is an outrageous and unacceptable situation. All of these deaths could easily be avoided through prevention and care programs for pregnant women that require simple and low-cost technology. The only thing lacking is public will.

In terms of contraceptive methods, an acute inequity also exists. In our region, the unmet demand for contraceptives in the wealthiest fifth of the population is 13%, while in the poorest fifth it is 42%. In other developing regions, such as Central Asia, the differences between the richest and poorest fifths are much less: only 3 percentage points. (Slide 2).

As a result of this situation, the fertility rates are high or very high among the poorest 20% of society: in Guatemala the fertility rate is 7.6 children; in Peru, 5.5; and in Brazil, a more developed country, the rate is 4.8 children. According to the United Nations, the differences in fertility rates among the poorest and wealthiest fifths of people in Latin America are the highest in the world.

Inequality also manifests in adolescent fertility rates. In Venezuela, the rate is 33 per thousand in the richest fifth and 173 per thousand in the poorest, over five times higher among poor girls.

The numbers I have cited clearly demonstrate that there is asymmetric access to reproductive health services in our region, which translates into an asymmetric exercise of human rights, whether the fundamental right to survival or the most basic reproductive rights. Generally, the poorest people don’t have access to sexual and reproductive health services or to the information they need to lead a decent life. Because they lack this kind of access, they end up vulnerable to situations such as unwanted pregnancy, maternal mortality and morbidity, HIV infection, or sexual violence that sink them further into poverty.

This is a sad situation in itself, but is even more regrettable because it could be avoided. We have contraceptive methods that prevent unwanted pregnancy. We have technology that can enable pregnancy without complications. We have the ability to teach safe sexual behavior. We have the capacity to treat the majority of sexually transmitted infections. We have the ability to provide safe abortion, whether through medication or manual aspiration. What we don’t have is the necessary will to make these resources widespread. 

In summary, in order to reach the Goals, governments and civil society must work together, guaranteeing access to sexual and reproductive health services to all people, regardless of their social or economic status.

The second obstacle I’d like to talk about is women’s empowerment in our region. In Latin America, as in many other parts of the world, women face disadvantages men do not, from unpaid domestic work to wage discrimination, as well as unequal access, use, and control of the means of production. In addition, women’s low level of empowerment limits the full exercise of their sexual and reproductive rights, even when these services are available. As a result of these inequalities, among the poorest sectors, women have an even more disproportionate participation.

The Millennium Goals have the advantage of recognizing women’s empowerment as a major aspect of development through Goal number three. However, its targets focus almost exclusively on the field of education, seeking to eliminate gender differences in education levels. Although this is a commendable goal, it is not especially appropriate for our region, as Latin America has to a large degree reached equality in education among men and women. According to ECLAC, equity in access to primary education was achieved in the 90s, while in terms of secondary and tertiary education levels, women have surpassed men in enrollment rates. We must therefore turn our attention to more pressing issues, such as combating gender-based violence, expanding and improving women’s participation in the labor market, achieving equal pay for the same work, and increasing women’s participation in the political process.

I would like to elaborate briefly on this last point, as women’s political participation is key to beginning to resolve all of the surrounding issues. Political equality is important to ensuring that women’s interests and needs are adequately represented, including their sexual and reproductive rights. Additionally, greater political participation by women helps to improve the quality of institutions. Various studies show that there is a positive correlation between increased political participation by women and a decrease in corruption levels. Finally, countries with high levels of female political participation are more inclusive, more egalitarian, and in short, more democratic.

In our region, on average, the proportion of seats held by women in national parliaments is about 16%, with exceptions such as Cuba, Costa Rica, Argentina and Guyana, which have over 30% representation. In order to advance towards more inclusive, egalitarian, and democratic societies, we must correct this imbalance.

The Millennium Project, which was created by request of the Secretary General of the United Nations in order to develop practical strategies to reach the Goals, has identified six strategic priorities to reaching gender equity and women’s empowerment. These were developed by the Project’s Working Group on Education and Gender Equality, which I had the privilege of participating in. The priorities range from guaranteeing sexual and reproductive health and rights to using quotas to increase women’s political representation.
 
As I mentioned earlier, there is currently an initiative presented by international women’s organizations that seeks to solve this problem through establishing a new UN agency which will be exclusively engaged in promoting women’s empowerment on a global scale. Without an agency to lead work in this area, gender equity and women’s empowerment will continue to be everyone’s responsibility, which is to say, no one’s.

Quotas at the national level and the new UN agency are important steps to reaching gender equity. Generally, to reach the Goal on women’s empowerment, civil society and government must coordinate and collaborate together to promote an agenda that will enable a rapid expansion of women’s rights, particularly in the field of politics.

The third obstacle refers to the fight against HIV/AIDS. With the current meager integration between HIV/AIDS programs and sexual and reproductive health programs, it will not be possible to reach this goal.

While HIV/AIDS rates are high in the Caribbean, they are not as high in Latin America. However, we should take into account the rapid growth of the epidemic in the whole region, particularly in Central America, as well as the little known fact, analyzed by the World Bank, that when compared to all infectious illnesses, the proportion of AIDS cases is higher in our region than in any other in the world. (Slide 3).
   
Facilitating the integration of the struggle against HIV/AIDS with sexual and reproductive health programs is essential to achieving significant advancement in combating this scourge, especially considering that the majority of new cases of infection are contracted through sex, birth, or breastfeeding. Also, HIV/AIDS as well as other problems related to sexual and reproductive health are affected by a set of common causes, including gender inequality, poverty, and marginalization. For this reason, it is both logical and practical to respond in collaboration to these issues.

The fourth obstacle or pending challenge is the need to generate the political will needed to mobilize these issues within our countries. Yet international agencies working in the field are abandoning our region. (Slide 4). Between 1999 and 2004, support from U.S. foundations to our region decreased by 50%. (Slide 5). And we receive about half of the assistance that Africa does from USAID. Many of the civil society organizations that drove the reproductive rights agenda in the past were funded by international organizations. Now this funding is running out and we must seek other sources for resources that will help us to continue moving forward our mission. We must be creative in our relationships with governments, individuals, and corporations in order to maintain the resources we need to continue promoting this agenda.

Finally, the fifth obstacle involves reducing maternal mortality. This goal cannot be reached without guaranteeing the exercise of our sexual and reproductive rights, including changing restrictive legislative frameworks regarding abortion. It is crucial that we mobilize public opinion and galvanize the necessary political support to change these laws that negatively and disproportionately affect the lives of low-income women. These women are the ones who must seek abortion under unsafe conditions, often resulting in death or serious health complications. Although we know that there are circumstances under which abortion is not criminalized in the majority of countries in our region, we also know that barriers impeding even this limited access also exist, with the power of choice delegated to health providers, hospital ethics committees, or judges.

We have achieved some progress during the last few years in this area, with laws liberalizing in Colombia, Guyana, as well as Mexico City, and we should celebrate these triumphs. But we also continue facing a serious risk of retreat, as demonstrated in the recent approval of a reactionary law in Nicaragua prohibiting abortion under all circumstances.

A sign of the increasing importance being given to this issue is the fact that five European governments have promised a total of ten million dollars to fund a Global Fund for Safe Abortion, which is managed by IPPF, and which to date has already received 200 applications from different regions in the world.

In conclusion, I would like to emphasize that the Goals, despite all of their shortcomings, can contribute to achieving our vision of human rights, which of course include sexual and reproductive rights, enabling the full development individuals and fulfilling the promise of citizenship. 

Although it’s obvious there are clear links between the Goals and a human rights framework, this does not mean that the resulting policies implemented by governments will automatically adapt to human rights standards. The Goals should therefore be more clearly steeped in a rights focus. National policies that seek to meet the Goals must be recognized as State obligations if they are to include a human rights perspective. In this way, the requirements of the Goals will in turn become rights that must be guaranteed.

A human rights focus highlights the fact that development is linked to a wider concept of freedom: freedom from poverty and suffering, from hunger, illiteracy, disease, and insecurity. Poverty and low levels of development are connected to a lack of respect, dignity, and with an inability to choose among different options. An adequate application of a human rights framework is most important to the poor and marginalized sectors of society; these are also exactly the same people who have the greatest stake in the attainment of the Millennium Development Goals. It’s clear that without a human rights focus, it will be impossible to reach them.

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