Carrying on from Cairo

In 1994, the International Conference on Population and Development demanded "reproductive health for all by 2015" in its programme of action. Padmasayee Papineni finds out if the programme is on course to achieve its aim

Over the last seventy years the global population has tripled, from 2 billion to 6.1 billion, and it continues to grow by about 77 million people a year.¹ The 1994 International Conference on Population and Development (ICPD) in Cairo marked an era of increasing sensitivity to the issues surrounding population growth--it extended national and international population policies beyond their demographic focus to encompass the broader issues of reproductive health and rights. The ICPD programme of action that was signed by 179 countries proclaimed "reproductive health for all by 2015." But 10 years after Cairo, has the enthusiasm generated by the ICPD translated into any real change in terms of access to services and protection of rights?

Embracing a rights based approach

In the 1960s international debates about population and health were dominated by birth control. In a speech to the United Nations, US president Lyndon Baines Johnson declared: "Let us act on the fact that less than five dollars invested in population control is worth a hundred dollars invested in economic growth." Then in the 1974 World Population Conference in Bucharest, debate implied that high fertility was a result of poverty, rather than a cause. Development was seen as the best contraceptive and the term population control became outdated--it emphasised demographic targets and focused on coercive policies.

The 1970s had seen the start of coercive methods of birth control. The "emergency period" in India saw the enforcement of compulsory sterilisation, and China's one child per family policy began. These policies encouraged discrimination against female children--between 1981 and 1991 about 1.2 million girls were "missing" in India due to neglect and infanticide. Evidence of such policies fuelled intense criticism of how population issues had been tackled by some countries.

JOHN McCONNICO/AP

Indian women visit a family
planning clinic in densely populated New Delhi

Then in Cairo in 1994 the debate shifted again and focused on a reproductive rights approach, which assumes that slower population growth depends on informed free choice, including access to reproductive health care. The resulting ICPD programme of action both defines reproductive health and also recognises it as a human right (box).

The agreement reached gave priority to female empowerment in a broad context to ensure reproductive rights. It included access to education for women, protection for women's legal rights, and commitment to greater activity of women in policy and decision making roles.

Despite initial increases in funding, the period after Cairo has failed to result in a significant change for the women who need most protection for their reproductive rights. The most recent available statistics on reproductive health highlight huge inequalities between the rich and poor. Findings on maternal mortality by the World Health Organization, UNICEF, and UNFPA show that a woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth. This compares with a 1 in 2800 risk for a woman from a developed region. Worldwide, 70% of all maternal deaths are accounted for by just 13 developing countries.³ These figures are mere estimates--maternal deaths are under-reported globally. The failure to measure maternal deaths accurately was described in the Lancet as violating reproductive rights because it, "denies women and their families the right for their health burden to be counted."⁴

Although these statistics give a pessimistic picture, advances have been made in some countries. Brazil has adopted a rights based approach by incorporating reproductive rights into national legislation.⁵ In Bangladesh, a national programme prioritising services has resulted in a decline in maternal mortality from 410 per 100 000 live births in 1998 to 320 in 2002.⁶ These cases show that reinforcement of reproductive rights can take place at many levels of policymaking, and when it is carried out does result in improvement.

The UNFPA website declares that 10 years after ICPD it is "keeping the promise"⁷ of reproductive health for all. But words are empty without actions, and actions empty without the funds needed to sustain them. In Cairo, estimates suggested that the international donor community needed to contribute $5.7bn (£3.2bn; ¤4.8bn) by 2000. However, total external assistance for population activities stood at less than half of this amount--$2.6bn in 2000--and fell in 2001.⁸ Compare these figures to the $5.5bn that is spent on chocolate each year in Britain,⁹ and the shortfall seems inexcusable.

However, funding is often subject to restrictions. Concern is currently being raised about the promotion of abstinence only programmes as a condition of HIV/AIDS funding. The USA is playing a powerful and disproportionate role in the field of global population policy through both funding and political convictions. In January 2001 the newly inaugurated president, George W Bush, reinstated the Mexico City Policy, which was initially announced by President Ronald Reagan in 1984. Under the policy, no money from the US family planning assistance funds can be provided to foreign organisations that use it to:

• Perform abortions in cases other than a threat to the life of the woman, rape, or incest;
• Provide counselling and referral for abortion; or
• Lobby to make abortion legal or more available in their country.

Known by its critics as the "global gag rule," non-compliance will result in loss of funding from the US Agency for International Development (USAID). Steve Sinding, director of the International Planned Parenthood Federation (IPPF), says: "With abortion legal in the US, the Mexico City Policy is in effect saying that women in developing countries don't have the same rights as American women, which I find morally repugnant."¹⁰

The organisation regards the global gag rule as a divisive attack on reproductive rights by forcing women to undergo unsafe abortion practices.¹¹ The Family Planning Association of Kenya (FPAK) lost its USAID funding and as a result had to close three of its urban clinics. Abortion is illegal in Kenya and FPAK clinics do not provide abortion. FPAK does, however, participate in active domestic discussion about abortion, meaning that they do not comply with the rule. One report estimates that more than 40% of Kenya's maternal mortality is due to unsafe abortion.¹²

JERRY CALLOW/PANOS

Chinese government propaganda said that if people had more
than one child, their following children would be deformed

International organisations have also been hard hit by the Mexico City Policy. The UNFPA is estimated to have lost 12% of its budget,¹³ and the International Planned Parenthood Federation lost 25% of its funding. With religious conservatism dominating the US perspective, the actions of the Bush administration have been described by researchers as "funding ideology, not evidence based policy."¹³ The risk of confrontation with the US is also believed to have dampened enthusiasm for the Cairo agenda from many developing countries.

ICPD+10--10 years after Cairo

The power to achieve change is more effective if countries are united rather than divided. The ICPD achieved a global consensus in appreciating that reproductive health is a fundamental human right, and some countries have begun to adopt its agenda. Steve Sinding of the IPPF says: "Access to reproductive health services is not a demographic imperative but a poverty reduction and women's empowerment imperative. Reproductive freedom is one of the liberating forces of the century."

But without commitment from those with the funds, access to reproductive health services is denied to millions of women. Of the estimated 529 000 maternal deaths in 2000, 99% occurred in developing countries, and the situation is getting worse in certain parts of the world. The Malawi Demographic and Health Survey (DHS) reported an almost 80% rise in the country's maternal mortality ratio from 620 maternal deaths/100 000 live births in 1992 to 1221 in 2000.¹⁴ Ten years on from Cairo, the promise of reproductive health still remains a distant hope for many who need it most.

Padmasayee Papineni fourth year medical student, University College London
Email: sweepypap@yahoo.co.uk


studentBMJ 2004;12:177-220 May ISSN 0966-6494

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