Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694818657960.pdf (Australia)
Submission to the Inquiry by the Joint Standing Committee on Foreign Affairs, Defence, and Trade into: The human rights issues confronting women and girls in the Indian Ocean – Asia Pacific region.
Head Office 85 Commercial Road, Melbourne, Victoria, Australia 3004 GPO Box 2284, Melbourne, Victoria, Australia 3001 www.burnet.edu.au Macfarlane Burnet Institute for Medical Research and Public Health Ltd ABN 49 007 349 984 1 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 Summary Our submission focuses on the barriers to improving the health of women and girls, recognising that health is one of the fundamental rights of every human being, and the consequent impact of poor health status on economic and social development.
Furthermore, we recognise that attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.

More than 200 million women in developing countries (around one in every four women) have an unmet need for modern methods of contraception.

Investing in contraceptive services to meet the global demand for family planning would lead to major health, social, and economic benefits.
Recommendation 1: The Australian aid program should ensure that commitments made at the 2012 London Family Planning Summit are met by FY 2015-­‐2016.

Australian funded family planning programs should focus on countries with high unmet need for contraception.

Recommendation 2: Funding for reproductive health in Pacific Island Countries is urgently required.
Funding for family planning in the Pacific region has fallen in the past decade to less than US$1 million per year compared with US$31 million spent on HIV.

An increased and long-­‐ term financial commitment for family planning is required.

We recognise that reducing maternal deaths is already a high priority of the Australian aid program and we applaud this position.

However, maternal mortality rates remain unacceptably high in Papua New Guinea (PNG) and Timor Leste.
Moreover, there is one aspect of maternal mortality that is neglected – unsafe abortions.

Worldwide approximately 22 million unsafe abortions, almost half of all induced abortions, occur each year, resulting in the deaths of 47,000 women.

Recommendation 3: Australia should continue to generously fund programs to reduce maternal mortality in the Indian Ocean-­‐Asia Pacific region and should increase the level of funding in PNG and Timor Leste.
Recommendation 4: Australian funded aid programs aiming to reduce maternal and neonatal mortality should have clear strategies to address unsafe abortions.

In addition to effective family planning services, these programs should manage abortion complications, provide contraceptive counselling and, where not against the law, safe abortion services.

About 19 per cent of young women in developing countries become pregnant before age 18, of which 28 percent are pregnant before the age of 15.
A pregnancy can have immediate and lasting consequences for a girl’s health, education and income-­‐earning potential.

Adolescent pregnancy is also associated with poorer health outcomes for girls and a 50% increased risk of stillbirth and newborn death compared with adult women.

Recommendation 5: Increase development assistance for programs that prevent adolescent pregnancies.

• Addressing adolescent pregnancy and improving access to family planning information and services needs to be prioritised.
• Greater funding for non-­‐government and civil society organisations that provide the bulk of sexual and reproductive health information and services for adolescents is also required.
2 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 • There is need for advocacy and support to ensure that adolescent pregnancy and access to family planning is explicitly addressed in national reproductive health and population policies and is integrated with other youth policies.
• Investment is required in strategies that create an enabling environment for adolescent girls – including prohibiting child marriage, removing legal and regulatory barriers that prevent access to sexual and reproductive health information and services (including family planning for unmarried young people), and combat forced and coerced sex.
• There is an urgent need for further research to better understand adolescents’ family planning knowledge, attitudes, practices, preferences and socio-­‐cultural context to inform policies and programs.

Many factors contribute to the elevated risk of adolescent girls for sexually transmitted infections (STI), including HIV.

Biologically, the immature reproductive and immune systems of adolescent girls translate to increased susceptibility to STIs and HIV transmission.
Many societal factors also contribute to the vulnerability of adolescent girls (and boys) to STIs.

In PNG, the rate of new HIV infections among women aged 15-­‐24 is three times the rate among men the same age.

A decade of evidence gathered worldwide has emphasised the usefulness of investing in youth development strategies for improving the short-­‐term and long-­‐term health of adolescents, including reproductive health.
Recommendation 6: Provide Australian funding and support for integrated adolescent sexual and reproductive health programs that include family planning and the prevention and treatment of STIs, including HIV, and that promote the sexual and reproductive rights of adolescents.

• Increase access by adolescent girls and boys to comprehensive, age-­‐appropriate sexual and reproductive health information and education through peer educators, schools, and mass/social media.
• Support youth-­‐friendly health services that are accessible, appropriate, and acceptable for adolescents.

• Take the opportunity to include other services relevant to adolescents, such as mental health, violence and injury prevention, immunisation, nutrition, and substance use harm reduction.

A new Global Investment Framework for Women’s and Children’s Health demonstrates how investment in reproductive, women’s and children’s health will secure high health, social, and economic returns.
Additional investments of just US$5 per person per year in 74 low and middle income countries, with 95% of the global maternal and child mortality burden, would yield high rates of return, producing up to nine times the economic and social benefit by 2035.
Australia was one of the four foundation members of the Alliance for Reproductive, Maternal and Newborn Health (along with the US, UK, and the Gates Foundation); as such, it is well positioned to play a leading role in advocacy within the international community to mobilise resources to implement the Framework.
Recommendation 7: The Australian aid program should continue to make significant investments in integrated reproductive, maternal, newborn, and child health in countries in the Indian Ocean-­‐ Asia Pacific region.

In addition, Australia should actively participate in international forums that seek to mobilise resources to implement the Global Investment Framework for Women’s and Children’s Health.

3 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 1.
About Burnet Institute Burnet Institute welcomes the opportunity to make this submission to the Joint Standing Committee on Foreign Affairs, Defence, and Trade.

Our mission is to achieve better health for poor and vulnerable communities in Australia and internationally through research, education and public health.
While our headquarters are in Melbourne, the Institute has offices in Papua New Guinea (PNG), Lao PDR, and Myanmar, as well as public health and research programs in China, India, Indonesia, Kenya, South Africa, Sri Lanka, Timor Leste, Vanuatu, and Zimbabwe.

The Institute has an annual turnover of approximately $40 million, of which more than one-­‐half supports our overseas programs.
Burnet Institute is the only Australian medical research institute to be accredited as an international development agency by the Department of Foreign Affairs and Trade, and the only Australian non-­‐government organisation to also be accredited as a Medical Research Institute by the National Health and Medical Research Council.

Burnet links medical research with public health action to improve the health of disadvantaged, poor, or otherwise vulnerable people throughout the world.
Sexual and reproductive health, young people’s health, and maternal and child health are thematic priorities of the Institute, with a geographical focus on the Indian Ocean-­‐Asia Pacific region.

Our staff includes medical scientists, clinical researchers, epidemiologists, public health professionals and educators with technical expertise in sexual and reproductive health, adolescent health, maternal health and infectious diseases.
Recognising that poor sexual and reproductive health, gender inequality and poverty are closely linked, Burnet engages in a broad range of research, development and policy activities focused on improving the health of women and girls in this region.

In particular, we seek to improve health outcomes for underserved and marginalised populations such as adolescent girls and women who sell sex.
Our work includes: laboratory-­‐based research and clinical trials of new diagnostic and prevention technologies to address the high burden of sexually transmitted infections (including HIV) among young women; public health research to better understand and respond to the sexual and reproductive health needs of adolescent girls in Asia and the Pacific; community-­‐based trials of interventions to reduce the burden of unintended pregnancy; technical support to UN agencies and other stakeholders to improve policy and programs aiming to address the sexual and reproductive health and rights of women and girls in Asia and the Pacific and reduce their unmet need for family planning; and development projects in PNG, Lao PDR, Myanmar and Zimbabwe to improve the care of women during pregnancy and childbirth and reduce preventable maternal morbidity and mortality.
Burnet also engages in evidence-­‐informed advocacy at the national, regional and global levels to support equitable progress towards universal access to reproductive health.
We are a member of the Asia Pacific Alliance for Sexual and Reproductive Health and a founding member of the International Sexual and Reproductive Health and Rights Consortium through which we advocate for sexual and reproductive health and rights of women and girls to be recognised as a critical global health, development and gender priority.

2.
2.

Introduction As a health-­‐focused NGO and medical research institute, we will focus on the barriers to improving the health of women and girls and the consequent impact of poor health status on economic and social development at the individual, family, community and national levels.

In the Indian Ocean-­‐Asia Pacific region, hundreds of millions of people remain trapped in extreme poverty – the majority living in what are classified as middle-­‐income countries.
These disadvantaged populations lack access to the benefits of socio-­‐economic development and neither consume from 4 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 nor contribute to the market economy.

One of the major constraints to poverty alleviation is poor health.

In low and middle income countries, women produce between 60 and 80 percent of the food; therefore, the poor health of women will adversely affect family incomes1.
In many parts of the Indian Ocean-­‐Asia Pacific region, gender inequalities and systematic discrimination make women disproportionately vulnerable to poverty, violence, HIV infection and other causes of ill health.

Women often have little control of their fertility, sexual and marital choices.
In comparison to men, women commonly lack legal recognition and protection, have less control over income and assets, less access to public knowledge and information, less decision making power within and outside their homes and reduced opportunities to participate in development.

Substantial reductions in maternal deaths have been achieved worldwide in the last two decades.

The global maternal mortality ratio declined by 47% between 1990 and 20102.
However, this falls short of the reduction needed by 2015 to achieve the Millennium Development Goal (MDG) to reduce maternal mortality by three quarters.

Despite rapid economic growth in many Asian countries, South Asia still accounts for one third of global maternal mortality.

Maternal causes are the second leading cause of death in women globally between the ages of 15 and 49, HIV being the leading cause2.

Our submission will focus in particular on sexual and reproductive health (SRH).
Ensuring universal access to SRH services is critical to improving the health of women and girls.

For example, meeting the need for family planning would reduce the number of maternal deaths globally by 29%3.

It is also central to other development priorities including the empowerment of women and girls and poverty reduction.

3.
3.

Response to the terms of reference Our submission will address the following terms of reference within the Inquiry: • barriers and impediments to enhancing the human rights of women and girls in the Indian Ocean -­‐ Asia Pacific region, especially regarding the impact of family and sexual violence, women's leadership and economic opportunities; and • implications for economic and social development in the Indian Ocean -­‐ Asia Pacific region of promoting women and girls' human rights.
3.1 Barriers to improving the health of women and girls According to the Constitution of the World Health Organization (WHO): "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being..." As a founding member state of the World Health Assembly, Australia recognises health as a universal human right.

Every country in the world is now party to at least one human rights treaty that addresses health-­‐related rights.
This includes the right to health as well as other rights that relate to conditions necessary for health.

One key determinant of the health of women and adolescent girls is reproductive rights.

Reproductive rights were clarified and endorsed internationally in the Cairo Consensus that emerged from the 1994 International Conference on Population and Development.

This 1 Food and Agriculture Organization (FAO), 2013.

Women and sustainable food security.

Rome: FAO Women and Population Division.


<http://www.fao.org/sd/fsdirect/fbdirect/fsp001.htm> (accessed 13 May, 2014).

2 WHO, UNICEF, UNFPA, World Bank.

Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and World Bank estimates.

2012. http://www.unfpa.org/webdav/site/global/ shared/documents/publications/2012/Trends_in_maternal_ mortality_A4-­‐1.pdf (accessed 15 May, 2014).

3 Office of the UN Secretary-­‐General’s Special Envoy for Financing the Health MDGs.
http://www.mdghealthenvoy.org/health-­‐ areas/maternal-­‐health/ (accessed 14 May 2014).

5 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 constellation of rights, embracing fundamental human rights established by earlier treaties, was reaffirmed at the Fourth World Conference on Women in Beijing in 1995.
Attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.
According to the United Nations Population Fund4, this includes the rights to: • Reproductive health as a component of overall health, throughout the life cycle, for both men and women; • Reproductive decision-­‐making, including voluntary choice in marriage, family formation and determination of the number, timing and spacing of one's children and the right to have access to the information and means needed to exercise voluntary choice; • Equality and equity for men and women, to enable individuals to make free and • informed choices in all spheres of life, free from discrimination based on gender; and Sexual and reproductive security, including freedom from sexual violence and coercion, and the right to privacy.
In late 2013, the leading medical journal The Lancet published a paper entitled “Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework” 5.

The conceptual framework recommended by the authors (who comprise The Lancet Commission on Investing in Health) has women, adolescent girls, mothers and newborns at the centre.
The core recommended interventions include prevention of unintended pregnancy and birth through contraception and reproductive health and effective care during pregnancy, birth and the postnatal period.

The framework is represented in the following figure: Figure 1: Conceptual framework for investment in women’s and children’s health (courtesy of The Lancet) 3.1.1 Preventing unintended pregnancy and birth 4 http://www.unfpa.org/rights/rights.htm 5 Karin Stenberg et al.
Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework.

The Lancet.

Published Online November 19, 2013. http://dx.doi.org/10.1016/ S0140-­‐6736(13)62231-­‐X 6 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 In 2012, 222 million women in developing countries had unmet need for modern methods of contraception6.
These women want to avoid pregnancy but are not using safe and effective family planning methods because they lack access to information and services or the support of their families and communities.

Subsequently there are more than 80 million unintended pregnancies every year (41% of all pregnancies), half of which end in induced abortion7.

Almost half of these abortions are clandestine and performed under unsafe conditions and associated with high rates of injury and death.
The need for voluntary family planning is growing fast, and it is estimated that the 'unmet need' will grow by 40 per cent during the next 15 years.

In Asia, 60 percent of women of reproductive age (15 – 49 years) were using a modern method of contraception in 2011, up from 50 percent in 19908.

The figure ranged from a low of 22 percent in Afghanistan and Timor Leste, 38 percent in Lao PDR, to more than 80 percent in Thailand and China.
In Sub-­‐Saharan Africa during the same period, contraceptive prevalence increased modestly from 15 to 25 percent.

However, it was higher in certain littoral countries of the Indian Ocean, such as 45 percent in Kenya and 34 percent in Tanzania.

In the Oceania region9, contraceptive prevalence fell from 60 percent in 1990 to 57 percent in 2011, with significant variation between countries, being only 32 percent in PNG, 34 percent in Solomon Islands, and 38 percent in Vanuatu.
From these figures, one can calculate that around one in four women in less developed regions has an unmet need for modern contraception, increasing to one in two women in Sub-­‐Saharan Africa6.

The continuing high level of unmet need for effective contraception has several implications for policies and programs.
The first need is for increased allocation of financial resources at the global and country levels to improve access to contraceptive services, secure commodity supplies and expand capacity where needed.
The second is to improve the quality of services—an important factor in whether women will use available services—including offering a range of methods to meet the different needs of women and couples, ensuring voluntary choice of methods, training staff to increase provision of accurate information and confidential and respectful care, giving priority to adequate counselling and follow-­‐up care, and facilitating switching methods.
Third, investment is needed in strategies to generate demand and community support and reduce socio-­‐cultural and other barriers to contraceptive use that impact on adolescent girls and women.

Investing in contraceptive services to meet the global demand for family planning would save an estimated US$5.7 billion in maternal and newborn health care costs, and avert an additional 1.9 million maternal and infant deaths10.
Indeed, meeting the demand for modern contraception alone would prevent almost a third of all maternal deaths.

Moreover, voluntary family planning is an effective way to prevent unwanted pregnancies so as to eliminate recourse to abortion, thereby saving women’s lives (every year, an estimated 47,000 women die as the result of unsafe abortions)7.

6 Darroch JE and Singh S: Guttmacher Institute, New York, USA.
Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys.

Published in The Lancet: May 18, 2013 (Vol.

381, Issue 9879, Pages 1756-­‐1762).

7 http://www.unfpa.org/rh/planning.htm (accessed 14 May 2014) 8 http://www.un.org/en/development/desa/population/theme/family-­‐planning/index.shtml (accessed 14 May 2014) 9 This region includes Australia and New Zealand.

10 Sing S, Darroch J.

Adding it up: costs and benefits of contraceptive services.
Estimates for 2012.

New York: Guttmacher Institute and UNFPA, 2012.

7 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 In July 2012, world leaders came together for a family planning summit in London.

Then foreign minister Bob Carr announced a doubling of Australian aid for family planning programs to more than $50 million a year by 2016.
The summit recommended focusing on the 69 countries with the highest unmet need for contraception, which include many countries in the Pacific, South and Southeast Asia.

It is not clear from the new government’s aid budget whether there is a specific allocation for family planning.

The Family Planning page on the DFAT website does not contain any information on the Australian Aid spend on family planning.
Recommendation 1: The Australian aid program should ensure that commitments made at the London Summit are met by FY 2015-­‐2016.

Australian funded family planning programs should focus on countries with high unmet need for family planning.

Recommendation 2: Funding for reproductive health in the Pacific region is urgently required.

Funding for family planning has fallen in the past decade to less than US$1 million per year compared with US$31 million spent on HIV.
An increased and long-­‐term financial commitment for family planning is required.

3.1.2 Effective care during pregnancy, birth and the postnatal period Modelled estimates of global maternal mortality for 2010 show a substantial decline in maternal deaths over the last two decades.

The number of women who die during pregnancy or childbirth has decreased nearly 50% globally since 1990—from 543,000 deaths to around 287,000 in 201011.
Although a huge reduction in global deaths among children under age 5 has been achieved, from more than 12 million in 1990 to 7.6 million in 2010, mortality is not being reduced uniformly, and reductions in newborn deaths lag behind survival gains among older children.

As a result, the share of newborn deaths in all deaths among children under age 5 has increased from 36% to 40% over the past decade11.

Interventions to reduce maternal deaths will also reduce newborn deaths.
The majority of maternal deaths are concentrated in Sub-­‐Saharan Africa and South Asia, an indication of global disparities in women’s access to needed obstetrical care and other services, including family planning and quality antenatal and postnatal care.

Nevertheless, there are several countries in Southeast Asia and the Pacific with extremely high maternal death rates.

Estimates of the maternal mortality ratio in PNG have varied between 230 and 730 per 100,000 live births.
However, a recent study estimated the true figure to be around 500 per 100,00012.

This is more than twice the maternal mortality in India and 70 times the rate in Australia.

In Timor Leste, maternal mortality remains one of the highest in the world––557 per 100 000 live births compared to a regional average of 8813.

We recognise that reducing maternal deaths is already a high priority of the Australian aid program and we applaud this position.
However, there is one aspect of maternal mortality that is neglected – unsafe abortions.

As stated by the Inter-­‐Agency Group for Safe Motherhood, “Unsafe abortion is the most neglected—and most preventable—cause of maternal death14.” Worldwide approximately 22 million unsafe abortions, almost half of all induced abortions, occur each year, resulting in the deaths of 47,000 women and temporary or permanent disability among an additional 5 million women11.
Almost all these deaths and disabilities occur in developing countries with highly restrictive abortion laws.

Although unsafe abortion rates are highest in Latin 11 World Health Organization and UNICEF.

Countdown to 2015.

Maternal, Neonatal and Child Survival.

The 2012 Report.

12 G Mola, B Kirby.

Discrepancies between national maternal mortality data and international estimates: the experience of Papua New Guinea.

Reproductive Health Matters 2013;21(42):191–202.


13 Timor-­‐Leste Demographic and Health Survey 2009–10.

14 http://www.safemotherhood.org/priorities/ 8 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 America and Sub-­‐Saharan Africa, they are also high in Indonesia, The Philippines, Myanmar, and Thailand and likely to be underestimated in many other countries due to underreporting.
Deaths due to unsafe abortion result mainly from severe infections, bleeding and organ damage caused by the procedure.

These deaths can be virtually eliminated by improving access to family planning and ensuring all women have access to comprehensive abortion services (including safe abortion and post-­‐abortion care for women who experience complications).
Indeed, experience from countries in this region that have reformed abortion legislation and improved access to safe services demonstrates that significant improvements in maternal health are achievable.

In South Africa, for example, revision of the abortion law led to a 91% decline in abortion-­‐related maternal mortality between 1994 and 200115.
Recommendation 3: Australia should continue to generously fund programs to reduce maternal mortality in the Indian Ocean-­‐Asia Pacific region and should increase the level of funding in Papua New Guinea and Timor Leste.

3.2 Recommendation 4: Australian funded aid programs aiming to reduce maternal and neonatal mortality should have clear strategies to address unsafe abortions.
In addition to the family planning services described in the previous section, these programs should manage abortion complications, provide contraceptive counselling and, where not against the law, safe abortion services.

3.3 3.1.3 Preventing pregnancies in adolescent girls Most of the world’s births to adolescents—95 per cent—occur in developing countries, and nine in ten of these births occur within the context of child marriage.
About 19 per cent of young women in developing countries become pregnant before age 1816.

Girls under 15 account for 2 million of the 7.3 million births that occur to adolescent girls under 18 every year in developing countries.

A pregnancy can have immediate and lasting consequences for a girl’s health, education and income-­‐ earning potential, perpetuating a cycle of gender inequality, disadvantage and poverty.
Pregnancy in adolescence also has inter-­‐generational effects—an adolescent girl is more likely to give birth to a low birthweight baby who is then more likely to be stunted as a child and have short stature as an adult woman, who will in turn be more likely to give birth to a low birthweight baby17.

Conditions related to pregnancy and childbirth are the second leading cause of death of adolescent girls aged 15-­‐19 years globally.
The risk of maternal death for mothers under-­‐15 in low-­‐ and middle-­‐income countries is double that of older females.

About 70,000 adolescents in developing countries die annually of causes related to pregnancy and childbirth.

Furthermore, around 3.2 million adolescent girls undergo unsafe abortions every year.
Additionally, infants born to adolescent mothers also suffer poorer health outcomes: the risk of stillbirth and newborn death is 50 per cent higher among adolescent mothers than adult women.12 15 Guttmacher Institute, Making abortion services accessible in the wake of legal reforms: a framework and six case studies.

New York: Guttmacher Institute, 2012. www.guttmacher.org/pubs/abortion-­‐ services-­‐laws.pdf> 16 UNFPA.

State of world population.

Motherhood in childhood.


Facing the challenge of adolescent pregnancy.

New York: United Nations Population Fund, 2013.

17 Qadir M and Bhutta Z, 2009.

Low Birth Weight in Developing Countries.

In: Kiess W, Chernausek SD, Hokken-­‐Koelega ACS (eds): Small for Gestational Age.

Causes and Consequences.

Pediatr Adolesc Med.

Basel: Karger, vol 13, p 148-­‐162.


9 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 Girls who are from an ethnic minority or marginalized group, who lack choices and opportunities in life, or who have limited or no access to sexual and reproductive health, including contraceptive information and services, are also more likely to become pregnant.

Girls who remain in school longer are less likely to become pregnant.
Leaving school—because of pregnancy or any other reason—can jeopardize a girl’s future economic prospects and exclude her from other opportunities in life.

Adolescent pregnancy is both a cause and consequence of rights violations.

Pregnancy undermines a girl’s possibilities for exercising her rights to education, health and autonomy, as guaranteed in international treaties such as the Convention on the Rights of the Child (which defines a “child” as anyone younger than 18).
Conversely, when a girl is unable to enjoy basic rights, such as the right to education, she becomes more vulnerable to becoming pregnant.

Figure 2 shows that eight percent of women in the East Asia-­‐Pacific region and 22 percent in South Asia report having had a baby before the age of 1812.
Figure 2: Research conducted by the Burnet Institute in Vanuatu identified that while prevention of pregnancy is important to adolescents, they currently receive little information about this compared with information about sexually transmitted infections and HIV18.

Compared with adults, adolescent boys and girls are less likely to have heard family planning messages in the media, and less than 25 percent of girls have discussed family planning with a health worker.
Research conducted by Burnet has highlighted the need to reach boys as well as girls to promote shared responsibility for prevention of early and unintended pregnancy.

18 Kennedy E, Gray N et al.

Identifying the sexual and reproductive health information and service delivery preferences of adolescents in Vanuatu.

Burnet Institute, on behalf of Compass: the Women's and Children's Health Knowledge Hub.

Melbourne, Australia; 2010.


10 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 Recommendation 5: Increase development assistance for programs that prevent adolescent pregnancies.
• Addressing adolescent pregnancy and improving access to family planning information and services needs to be prioritised • Greater funding for non-­‐government and civil society organisations that provide the bulk of SRH information and services for adolescents is also required • There is need for advocacy and support to ensure that adolescent pregnancy and access to family planning is explicitly addressed in national reproductive health and population policies and is integrated with other youth policies Investment is required in strategies that create an enabling environment for adolescent girls – including prohibiting child marriage, removing legal and regulatory barriers that prevent access to sexual and reproductive health information and services (including family planning for unmarried young people), and combat forced and coerced sex • • There is an urgent need for further research to better understand adolescents’ family planning knowledge, attitudes, practices, preferences and socio-­‐cultural context to inform policies and programs.
3.1.4 Preventing sexually transmitted infections (STI) in adolescent girls (and boys) Many factors contribute to the elevated risk of adolescent girls for STIs, including HIV.

Biologically, the immature reproductive and immune systems of adolescent girls translate to increased susceptibility to STIs and HIV transmission.

Many societal issues also contribute to risks for adolescents.
Age diﬀerences between heterosexual partners (younger girl and older male partner), gender diﬀerences in norms for sexual behaviour (eg, sexual involvement expected for boys and men while negatively sanctioned for girls and women), and early marriage for girls could all heighten the possibility of sexual coercion.

Moreover, in much of the developing world, some young women experience pressure to become sex workers as the only available option for contributing to the food and shelter needs of their family.
In most countries of the world, the sexual debut of unmarried young people has been taking place at an earlier age.

For example, in the Pacific recent data indicate that up to 65 percent of girls and 72 percent of boys aged 15-­‐19 years have ever had sex, with a significant proportion reporting sexual debut before the age of 1519.

A survey of young people in a peri-­‐urban area of Port Moresby found that the median age of sexual debut in both boys and girls was 16 years20.
Adolescents may be less likely than adults to access condoms through lack of knowledge, shyness, or social prohibitions.

For example, a survey in The Philippines of sexually active adolescents aged 15-­‐19 found that only 22% of boys and 27% of girls used a condom the last time they had sex21.

The prevalence of HIV is higher in adolescent girls than in adolescent boys in almost all developing countries.
For example, in PNG between 1987 and 2010, the rate of new HIV infections among young women aged 15-­‐24 was three times the rate in young men of the same age22.

19 Macro International: Demographic and Health Surveys in Solomon Islands (2009), Samoa (2010), Tuvalu (2007), Nauru (2007), Marshall Islands (2007), Papua New Guinea (2009), and Kiribati (2010).

20 John Millan, William Yeka, Walter Obiero, Joachim Pantumari.

HIV/AIDS Behavioural Survey Within High-­‐Risk Settings.

Papua New Guinea.

2006.


Report to AusAID by the National HIV/AIDS Support Project.

September 2007.

21 Linda H Bearinger, Renee E Sieving, Jane Ferguson, Vinit Sharma.

Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential.

The Lancet 2007; 369: 1220–31.

22 PNG National Department of Health.

STI, HIV and AIDS Surveillance Unit.

The 2010 STI, HIV and AIDS Annual Surveillance Report.

September 2011.
September 2011.

11 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 The most basic needs of adolescents, regardless of culture, age, and marital status, are for accurate and complete information about their body functions, sex, safer sex, reproduction, and sexual negotiation and communication skills.
Gender-­‐sensitive, comprehensive sexuality education programs that address these components have been demonstrated to have a positive impact not only on knowledge and attitudes, but also contribute to safer sexual practices (such as delaying sexual debut, reducing the number of partners, and increasing condom and contraceptive use) and can also reduce the negative consequences of unsafe sex23.
Despite this evidence, access to comprehensive sexuality education throughout the Indian Ocean-­‐Asia Pacific region remains limited.

Without information, adolescents are forced to make poorly informed decisions that may have profound negative effects on their lives.

A decade of evidence gathered worldwide has emphasised the usefulness of investing in youth development strategies for improving the short-­‐term and long-­‐term health of adolescents, including reproductive health.
Data repeatedly show the effectiveness of investment in aspects of adolescents’ lives that can protect them from harm and prepare them for effective entry into adult roles16.

One key element in adolescent development is the recognition of their sexual and reproductive rights, as defined at the 1994 Cairo Conference on Population and Development.
Sexual and reproductive rights refer to the rights of individuals, who are free of coercion, to the highest attainable standard of sexual health, and a satisfying and safe sexual life, and to be able to choose their partner, whether or not to be married or to be sexually active, and to decide when to have children.

It requires access to health-­‐care services and sexuality education16.
Recommendation 6: Provide Australian funding and support for integrated adolescent sexual and reproductive health programs that include family planning and the prevention and treatment of STIs, including HIV, and that promote the sexual and reproductive rights of adolescents.
• • • Increase access by adolescent girls and boys to comprehensive, age-­‐appropriate SRH information and education through peer educators, schools, and mass/social media Support youth-­‐friendly health services that are accessible, appropriate, and acceptable for adolescents Take the opportunity to include other services relevant to adolescence, such as mental health, violence and injury prevention, immunisation, nutrition, and substance use harm reduction.
3.2 Implications for economic and social development of promoting women and girls' health and rights A new Global Investment Framework for Women’s and Children’s Health demonstrates how investment in reproductive, women’s, newborn’s, and children’s health will secure high health, social, and economic returns24.
Developed by the Study Group for the Global Investment Framework for Women’s and Children’s Health, which includes the current DFAT senior health advisor, they costed health systems strengthening and six investment packages for: family planning, maternal and newborn health, child health, immunisation, HIV and AIDS, and malaria.

Nutrition is a cross-­‐cutting theme.

They then used simulation modelling to estimate the health and socioeconomic returns of these investments.
Additional investments of US$5 per person per year in 74 low and middle income countries, with 95% of the global maternal and child mortality burden, would yield high rates of return, producing up to nine times the economic and social benefit by 2035.

23 Kirby D. The impact of sex education on the sexual behaviour of young people.

Population Division.

Expert Paper No.2011/12.

New York: United Nations Department of Economic and Social Affairs, 2011 24 Karin Stenberg et al.
Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework.

The Lancet.
The Lancet.

Published Online November 19, 2013. http://dx.doi.org/10.1016/ S0140-­‐6736(13)62231-­‐X 12 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47 Compared with current trends, this accelerated investment scenario estimates that a total of 5 million maternal deaths, 147 million child deaths, and 32 million stillbirths can be prevented in 2013–35 in 74 high-­‐burden countries.
Expanding access to contraception will be a particularly cost-­‐ effective investment potentially accounting for half of all the deaths prevented in the accelerated investment scenario.

More than a third of the additional costs required are health systems investments that are also required for services beyond those for reproductive, maternal, newborn, and child health.
In addition to the substantial impact on maternal and child health, investing in sexual and reproductive health is also central to achieving other global development priorities such as women’s empowerment and poverty reduction.

Reducing unmet need for family planning and preventing adolescent pregnancies has profound benefits in terms of increasing educational attainment of girls and improving women’s economic and political participation25.
It can also result in large public sector savings and increased productivity.

Modelling conducted by Burnet Institute in 2012 estimated that for every US$1 invested in family planning to reduce unmet need in the Pacific, between US$9-­‐16 would be saved in health and education costs – equivalent to over US$112 million in the next 15 years26.
Australia was one of the four foundation members of the Alliance for Reproductive, Maternal and Newborn Health, established in 2011—along with the US Agency for International Development, the UK’s Department for International Development, and the Bill & Melinda Gates Foundation—which is helping governments and other partners to accelerate progress toward MDGs 4 and 5 in ten priority countries.
They include seven countries in the Indian Ocean -­‐ Asia Pacific region: Bangladesh, India, Indonesia, Kenya, Nepal, Pakistan and Tanzania.

The Alliance hosted the Family Planning Summit in London, where donors made financial commitments amounting to $2.6 billion27.
Alliance partners are collaborating with the Partnership for Maternal, Newborn and Child Health to promote the implementation of the new global guidance “Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health28.” Given this high-­‐profile role, Australia is well positioned to play a leading role in advocacy within the international community to mobilise funding to implement the Global Investment Framework for Women’s and Children’s Health described above.
Moreover, Australia could actively promote the integrated approach proposed in the framework.

Recommendation 7: The Australian aid program should continue to make significant investments in integrated reproductive, maternal, newborn, and child health in countries in the Indian Ocean-­‐Asia Pacific region.

In addition, Australia should actively participate in international forums that seek to mobilise resources to implement the Global Investment Framework for Women’s and Children’s Health.
25 Canning D, Schultz TP.

The economic consequences of reproductive health and family planning.

Lancet.2012.

26 Kennedy E, Mackesy-­‐Buckley S, Subramaniam S, Demmke A, Latu R, Robertson, A, Tiban K, Tokon A, Luchters S. The case for investing in family planning in the Pacific: costs and benefits of reducing unmet need for contraception in Vanuatu and the Solomon Islands.

Reproductive Health.

2013;10:30.

27 2012 Progress Report.

Alliance for Reproductive, Maternal and Newborn Health.
http://www.usaid.gov/sites/default/files/documents/1864/rmnh_alliance_year2.pdf 28 http://www.who.int/pmnch/knowledge/publications/201112_essential_interventions/en/ 13 Human rights issues confronting women and girls in the Indian Ocean – Asia Pacific regionSubmission 47