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Contraception Editorial June 2011

International Reproductive Health Still Worth The Investment

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Suzanne Petroni, PhD, Wayne C. Shields

The United States has been a global leader in the international population arena for nearly 50 years. United States investments in maternal, reproductive and sexual health programs have been a tremendous success, saving and improving many millions of lives. But many challenges remain, and the collective education and advocacy efforts of the sexual and reproductive health community can help overcome them.

The world's population continues to grow at a rate of nearly 80 million people a year.1 An estimated 215 million women throughout the developing world want, but do not have access to, modern methods of contraception, which contributes to some 76 million unintended pregnancies and 20 million unsafe abortions each year.2 The number of women who die during childbirth remains unacceptably high, with hundreds of thousands still succumbing to mostly preventable maternal deaths each year.3 Hundreds of thousands more women are injured during pregnancy, with tens of thousands facing the tragedies of obstetric fistulae or unsafe abortions.3 AIDS is now the leading cause of death among women of reproductive age, and maternal mortality is the leading killer of women aged 15–19 years throughout the world.4 Because of gender discrimination and sociocultural beliefs, young women are particularly ill-equipped to negotiate safer sex practices with their typically much older partners.

Access to comprehensive sexual and reproductive health services can solve many of these grave challenges, and for many decades, the United States has supported the provision of such services for women and men in the developing world. At the International Conference on Population and Development (ICPD), held in Cairo, Egypt in 1994, the United States led the world — and joined leaders in health, science, medicine, women's rights and the environment — in committing to provide the funding and support needed to meet the world's reproductive health needs.5

In recent years, however, US policies around these issues have become increasingly divisive and politicized, contributing to insufficient funding and constrained programs. Indeed, while not all programs supported by the US government are as efficient as they might otherwise be — operating as they do in silos, with ideologically driven restrictions, and sometimes in competition with each other — the assistance that the US provides to address the sexual and reproductive health needs of the world's poorest people is absolutely critical and lifesaving. These investments must be protected from a new Congress, which seeks to curtail funding for development assistance, and they must be supported by an Administration that has made promising initial steps toward breaking down barriers and meeting the commitments made by the United States.

The significant progress that has been made in the past half century will be lost unless the United States and other nations reinforce their commitment to the ICPD agenda and to the notion that women's health is worth protecting.

What did the world agree to in Cairo? 

The ICPD Programme of Action, arduously negotiated over many months, was a comprehensive document that reached across a broad range of issues associated with population and development, including, but not limited to, education; infant, child and maternal mortality; population dynamics; the environment and consumption; migration; HIV/AIDS; and technology, research and development.5

While far-reaching in scope, the core of the ICPD was recognition that a sustainable world was not about numbers, but about people, and that all people, particularly women, must have access to reproductive health. This worldwide consensus recognized that achieving universal access to reproductive health is critical for individual health, family well-being, economic development and a healthy planet.

Reproductive health was defined at Cairo in more comprehensive terms than ever before, namely, as “a state of complete physical, mental and social well-being … in all matters relating to the reproductive system.” This meant expanding the definition beyond family planning — long the mainstay of population programs — to include maternal and neonatal health; prevention and treatment of sexually transmitted infections, including HIV/AIDS; and prevention and response to gender-based violence — all-critical elements of achieving universal access. Women's empowerment, including their right to determine the number, timing and spacing of childbearing, was given paramount importance at Cairo.

The ICPD also encouraged breaking down the silos in which sexual and reproductive health programs had traditionally been divided, an innovative way to advance a more holistic— and realistic — view of health.

The ICPD agenda is as needed as ever 

The United States was one of 179 nations that made a commitment in Cairo to help advance the health and welfare of women, men and young people around the world. This commitment was made out of a moral obligation to ensure that individuals can rise out of desperate poverty, a conviction that women and children should not suffer and die needlessly, and as a practical investment in our shared future. Some 17 years later, the principles and goals of Cairo are as relevant and needed as ever.

As health care researchers and providers know, sexual and reproductive health care is a critical component of the overall health and welfare of women, men and young people. Individuals' welfare contribute to the welfare of communities, nations and ultimately the world. Their sexual and reproductive health status impinges greatly on the decisions of women, men and young people, and impacts their access to needed information, care and services.

Even as we face a global population that will soon number an historic seven billion, we can continue to advance toward a healthier, more equitable and sustainable world.6 Working in partnership with other nations around the world, we have a responsibility to do so.

We know what works 

Despite the many challenges, we know from successful investments in global health that solutions are within reach.

Supporting the comprehensive package of simultaneous interventions recommended by the ICPD will ensure that voluntary contraception is affordable and safe; that women are empowered to decide whether and when they want to have a baby; that evidence-based sexuality education programs reach all those in need, so that unintended pregnancies and sexually transmitted diseases are prevented. These interventions will ensure that pregnant women have access to lifesaving information for themselves and their children, and that they give birth with skilled assistance. They will ensure that young women are not subject to sexual violence, including culturally driven practices, like female genital circumcision, that impair their rights and their sexual health.

What has been proven NOT to work are siloed programs and ideologically driven policy restrictions — such as the Mexico City Policy or “Global Gag Rule” that restricts family planning funding from organizations that provide — with their own funds — abortion counseling, lobbying or services.7

Comprehensive solutions are effective. Maternal mortality rates in Egypt have dropped by more than 50%, as contraceptive usage increased from 23% in 1980 to 57% in 2005. In Mexico, the infant mortality rate fell by 70% between 1970 and 2005, as the use of modern contraceptives and access to prenatal care increased.8 In the past 3 years alone, more than 6000 communities in eight sub-Saharan African nations have abandoned female genital mutilation.9 The number of people infected with HIV/AIDS in Zimbabwe nearly halved in a 10-year period: from 29% of the population in 1997 to 16% in 2007, as awareness about prevention methods increased.10 Similar successes appear in every corner of the world.

Fortunately, what works is supported by the American public 

These are cost-effective elements of US foreign policy, and they are supported by an overwhelming majority of Americans across the political spectrum. According to American Public Opinion and Global Health (May, 2009), 68% of Americans said they support “helping poor countries provide family planning and reproductive health services to its citizens.” Some 78% support “improving the health of mothers and children in poor countries".11 And according to the Kaiser Family Foundation, 85% of Americans think “promoting the rights of women” should be a top priority for the US government.12

The Obama Administration is on board … mostly 

The Obama Administration has recognized that we must not roll back the significant progress that has been achieved thus far, and has taken specific, concrete steps to advance more comprehensive, integrated, evidence-based approaches to sexual and reproductive health and women's rights. The Global Health Initiative (GHI), a hallmark of the Administration's international development policy, would institutionalize a cross-disciplinary and cross-agency approach to the challenges laid out in Cairo, breaking down the silos that have long hampered effective development assistance.13 Based on years of successes and understanding that women's health and rights are absolutely essential to ensuring the health of communities and the world, the GHI is powerfully focused on interventions to prevent unintended pregnancy, promote women's health and save women's lives.

The GHI also recognizes the importance of innovation in achieving global health solutions. We hope that this recognition will lead to increased support by the Administration of new innovations to advance sexual and reproductive health, such as multipurpose prevention technologies that would allow women to simultaneously prevent unintended pregnancy and a range of sexually transmitted infections.14 Multipurpose prevention technologies represent the ideal illustration of working across issue silos to address the holistic health needs of women.

The creation of an Office of Global Women's Issues, led by an ambassadorial-level appointment and reporting directly to the Secretary of State, and whose staff has been intimately engaged in advancing the GHI, is yet another indication of the prioritization of women and women's health in US foreign policy and assistance.

And while we would argue that it does not go nearly far enough, President Obama's budget request for Fiscal Year 2012 included necessary increases in funding for international reproductive and maternal health programs.

Call to action 

In more cases than not, the smartest long-term strategies build on what is proven to work with an infusion of fresh data and a dash of creativity. The Cairo principles have proven to work and serve to inform specific strategies to raise the standards of health and quality of life for women and their families in all nations.

It is important for all nations to show global leadership by continuing to break down barriers between disciplines, specialties, agencies and interest groups to address common public health goals. A sustained, long-term US commitment to advancing reproductive health is the way to make progress. Some countries are meeting their commitments to advance reproductive health, but the United States is not. In order to meet its fair share of the Cairo agenda and keep its promise to the world's women, the US government should provide $3.2 billion for maternal, newborn, child and reproductive health programs and advance policies that ensure these funds are used effectively to meet the health needs of individuals. With adequate funding and appropriate policies, the United States can help to prevent the deaths of hundreds of thousands of women and children, reduce the spread of HIV/AIDS, grow economies, make poverty history and preserve natural resources the world over.

Cairo represented a watershed moment for the development and implementation of global health strategies, and we are on the right path — but the huge potential of these basic principles to create monumental changes in reproductive health globally has yet to be realized.

What you can do 

To be most effective, policies should be evidence based and meet real-life needs. As reproductive health professionals, you rely on this approach to ensure the greatest likelihood of public health success. Your professional voice holds more sway than you might think.

Here is what you can do:

  1. Include information about the Cairo principles and our global progress when developing any relevant curriculum, continuing medical education program, speech, interview or other outreach platform.
  2. Initiate conversations with professional colleagues, policymakers, educators, religious leaders, members of the media and others to advocate for basing policy decisions on evidence — not ideology — and to support necessary national funding to reach the Cairo goals.
  3. Show your support for evidence-based policies and the Cairo principles by encouraging policymakers to provide support to the world's women and increase funding levels to meet the commitments of support.
  4. Sign up for professional updates and helpful links to vetted information resources (government agencies, nongovernmental organizations, global health advocacy groups and donors, and others): www.arhp.org/supportglobalhealth. We encourage your support, advocacy and constructive comments.

Suzanne Petroni
Vice President for Global Health
Public Health Institute

Wayne C. Shields
President and CEO
Association of Reproductive Health Professionals

References

  1. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat . World population prospects: the 2008 revision. United Nations. http://esa.un.org/unpp Last accessed February 17, 2011. Susheela S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: the benefits of investing in family planning and newborn and maternal health. Guttmacher Institute and United Nations Population Fund, 2009. http://www.guttmacher.org/pubs/AddingItUp2009.pdf Last accessed February 22, 2011..
  2. In: WHO , UNICEF , UNFPA , World Bank  editor. Maternal mortality in 2005. Geneva: World Health Organization; 2007;p. xiv, 10;http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html Last accessed February 17, 2011.
  3. World Health Organization . Women and health: today's evidence tomorrow's agenda. Geneva: WHO Press; 2009;http://www.who.int/gender/women_health_report/en/index.html Last accessed February 22, 2011.
  4. ]International Conference on Population and Development: summary of the programme of action . United Nations Department of Public Information. http://www.un.org/ecosocdev/geninfo/populatin/icpd.htm Last accessed February 17, 2011.
  5. Development Data Group, World Bank. In: 2009 World development indicators. Washington, DC: International Bank for Reconstruction and Development/The World Bank; 2009;p. 43.
  6. Cincotta RP, Crane BB. Public Health. The Mexico City policy and U.S. family planning assistance. Science. 2001;294(5542):525–526.
  7. Mortality country fact sheet, 2006. World Health Organization. 2006. Available at: http://www.who.int/whosis/mort/profiles/mort_emro_egy_egypt.pdf. Last accessed February 17, 2011.
  8. UNFPA, UNICEF . The end is in sight: annual report 2009 for the UNFPA/UNICEF Joint Programme on Female Genital Mutilation/cutting. 2010;http://www.unfpa.org/public/home/publications/pid/6435 Last accessed February 17, 2011.
  9. Halperin DT, Mugurungi O, Hallett TB, et al. A surprising prevention success: why did the HIV epidemic decline in Zimbabwe?. PLoS Med. 2011;8:e1000414.
  10. Ramsey C, Weber S, Kull S, Lewis E. Americans support US working to improve health in developing countries. World Public Opinion, Inc. (May 20, 2009). http://www.worldpublicopinion.org/pipa/articles/brunitedstatescanadara/610.php Last accessed February 17, 2011.
  11. Survey about U.S. role in global health reports that Americans want to take care of problems at home first in a recession, but say don't cut funding for global health and development. Public Opinion and Research Program, Henry J. Kaiser Family Foundation (May 6, 2009). http://www.kff.org/kaiserpolls/posr05609pkg.cfm Last accessed February 17, 2011.
  12. The US Government's Global Health Initiative. PEPFAR, United States Department of State. Available at: http://www.pepfar.gov/ghi/index.htm. Last accessed February 17, 2011.
  13. Initiative for Multipurpose Prevention Technologies (MPT) . Coalition advancing multipurpose innovations. http://www.cami-health.org/Initiatives.html Last accessed February 17, 2011.

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Used with permission from Elsevier, Inc.