state of world population 2019
UNFINISHED BUSINESS: the pursuit of rights and choices for all

Ensuring rights and choices for all since 1969
United Nations Population Fund
605 Third Avenue
New York, NY 10158+1 (212) 297-5000
www.unfpa.org@UNFPAISSN 1020-5195
ISBN 978-0-89714-029-4

Sales No. E.19.III.H.1
E/4,221/2019
Printed on recycled paper.

UNFINISHED

BUSINESS
the pursuit of rights and choices FOR ALL

State of World Population 2019
This report was developed under the auspicesof the UNFPA Division of Communications
and Strategic Partnerships.
EDITOR-IN-CHIEF
Arthur Erken, Director, Division of Communications
and Strategic Partnerships
EDITORIAL TEAM
Editor: Richard Kollodge
Editorial associate: Katie Madonia
Digital edition manager: Katie Madonia
Digital edition advisers: Hanno Ranck, Katheline Ruiz
Publication and web design: Prographics, Inc.
RESEARCH ADVISER AND WRITER
Stan Bernstein
UNFPA TECHNICAL ADVISERS
Elizabeth Benomar
Daniel Schensul
LEAD RESEARCHER AND WRITER
Kathleen Mogelgaard
CHAPTER RESEARCHERS AND WRITERS
Jeffrey Edmeades
Gretchen Luchsinger
William A. Ryan
Ann M. Starrs
FEATURE WRITERS
Janet Jensen
Gretchen Luchsinger© UNFPA 2019ACKNOWLEDGMENTS
UNFPA thanks the following women for sharing glimpsesof their lives for this report:
Tefta Shakaj, ALBANIA
Mediha Besic, BOSNIA AND HERZEGOVINATsitsina Xavante, BRAZIL
Say Yang, CAMBODIA
Dahab Elsayed and Um Ahmed, EGYPT
Alma Odette Chacón, GUATEMALA
Marta Paula Sanca, GUINEA-BISSAU
Fanie Derismé, HAITI
Rajeshwari Mahalingam, INDIA
Shara Ranasingh, SRI LANKA
Rasamee, THAILAND
Josephine Kasya, UGANDA
The editors are grateful to William McGreevey for research on
institutional and financing obstacles to sexual and reproductive
health and to Christopher Hook for other research assistance.
The Population and Development Branch of UNFPA aggregatedregional data in the indicators section of this report. Source
data for the report’s indicators were provided by the Population
Division of the United Nations Department of Economic andSocial Affairs, the United Nations Educational, Scientific andCultural Organization and the World Health Organization.
Rachel Snow, Sara Reis and Marielle Sander-Lindstrom fromUNFPA also contributed to the shaping of this year’s report.
Erin Anastasi, Emilie Filmer-Wilson, Anneka Knutsson andLeyla Sharafi reviewed and commented on drafts.
MAPS AND DESIGNATIONS
The designations employed and the presentation of material
in maps in this report do not imply the expression of any
opinion whatsoever on the part of UNFPA concerning the legal
status of any country, territory, city or area or its authorities,
or concerning the delimitation of its frontiers or boundaries.
A dotted line approximately represents the Line of Control in
Jammu and Kashmir agreed upon by India and Pakistan. The
final status of Jammu and Kashmir has not been agreed uponby the parties.
PHOTOGRAPHY
Front cover: © Steve McCurry/Magnum Photos
Timeline: © Alamy Stock Photos, Getty Images,
Jangbu Sherpa, Warren K. Leffler, NASA,
UN/UNFPA

Ensuring rights and choices for all since 1969

UNFINISHED

BUSINESS
the pursuit of rights and choices FOR ALL

1

The struggle for rights andchoices is an ongoing one

page 72

Six women, six decades,
six journeys

page 23

3

Rights at risk in timesof population growth

page 37

Available but
inaccessible

page 53

The obstacle underlying
all others

page 73

6

When services
collapse

page 87

7

Institutions and funding toensure rights and choices

8

Realizing rights and choices
for all: If not now, when?

page 117

9

More than my mother,less than my daughter

page 137

4
5© Cristina Garcia Rodero/Magnum Photos

page 101

Remarkable gains have been made insexual and reproductive health and rights
since 1969, when UNFPA was established.
But despite progress, hundreds of millions
of women today still face economic,
social, institutional and other barriers
that prevent them from making their own
decisions about whether, when, how often
and with whom to become pregnant.

The pursuit of rights
and choices is an
ongoing one, withnew challenges
emerging all
the time.

FOREWORD

Make rights and choices a reality for all
It was 1969. World population reached 3.6 billion,

Since its creation in 1969, UNFPA has led aup about 1 billion from only 17 years earlier. Fertility

multilateral effort to help women in developing

rates worldwide then were about double what theycountries navigate through an ever-changing

are today. In the least developed countries, fertility

landscape of barriers to their reproductive rights.

was about six births per woman.

This effort gained new momentum and inspirationin 1994, when 179 governments gathered in Cairo

Paul Ehrlich’s The Population Bomb, released thefor the International Conference on Population andyear before, had incited a global panic about

Development and forged a plan for sustainable“overpopulation,” which the author predicted would

development grounded in individual rights andlead to mass starvation on a “dying planet.”choices and the achievement of sexual andreproductive health for all. That plan, embodied

It was in that context that UNFPA was establishedin a Programme of Action, not only re-energized

to advise developing countries about the social

the global reproductive rights movement but also

and economic implications of population growth

positioned UNFPA as the movement’s custodian.

and to support national population programmes,
which began dispensing contraceptives on an

The combined actions of civil society, governments,

unprecedented scale.

development institutions and UNFPA over the
past 50 years have unlocked opportunities andThrough these programmes, real reproductive

possibilities for women and girls across the globe.

choices became a reality for more and more

Yet, we still have a long way to go before all women

women in developing countries. And as a result,and girls have the power and the means to govern

women started having fewer children. Millions

their own bodies and make informed decisions about

were finally gaining the power to control their

their sexual and reproductive health.

own fertility.
At the same time, we must push back against forces
Despite the increasing availability of contraceptives

that would see us return to a time when womenover the years, hundreds of millions of women

had little say in reproductive decisions or, for thattoday still have no access to them—and to thematter, in any area of their lives.

reproductive choices that come with them.
Without access, they lack the power to makeThe fight for rights and choices must continue until

decisions about their own bodies, including

they are a reality for all.

whether or when to become pregnant.
Dr. Natalia Kanem
The lack of this power—which influences so

United Nations Under-Secretary-Generalmany other facets of life, from educationand Executive Director of UNFPA,

to income to safety—leaves women unable

the United Nations Population Fundto shape their own futures.

4© Digby Oldridge/PR Eye Bespoke Photography

1969
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© Gilles Peress/Magnum Photos

CHAPTER 1

THE STRUGGLEFOR RIGHTS ANDCHOICES IS AN
ONGOING ONE
The year 2019 marks two important milestones in the field ofreproductive health: 50 years since UNFPA began operations, and25 years since the landmark International Conference on Population
and Development (ICPD) in Cairo.
These two events—the launch of thefirst United Nations agency dedicated to addressing population growth
and the reproductive health needsof the world’s people, and the declaration of a global commitment tosexual and reproductive health andreproductive rights—have fundamentally shaped the lives of womenand families, and the societies inwhich they live, in ways measurable
and immeasurable, profound andtrivial, permanent and fleeting.
Activists, advocates, public healthspecialists and many others havepushed relentlessly for the transformations we see around us today,
but much remains to be done.

What the future holds in termsof changes in population growth,
contraceptive use and sexual andreproductive health and rights willboth determine and be determinedby the ability of women and girls toachieve their full potential as members of their societies. And this will
be determined, in no small part, by

STAT E OF WOR L D POPUL AT I ON 2 01 9

7

how the world takes forward theachievements and addresses theshortfalls of the ICPD to date.

The world in 1969
Fifty years ago around the world,
the average woman had 4.9 children, and 35 per cent of married

women were using some form ofcontraceptive method to delay or
prevent pregnancy; in the least
developed countries, however,
the average woman had 6.7 children, and about 2 per cent wereusing a method of contraception.
Abortion was illegal in much of

the world, and the women’s liberation movement was fighting
for equality in access to education, employment opportunities
and pay, marriage and divorce,property ownership, and on a
range of other fronts. In 1969,
the Stonewall Riots in New York1969
TO2019World events

andUN MILESTONES▲RAFAEL SALAS NAMEDUNFPA EXECUTIVE DIRECTOR
THE UNITED NATIONS FUND
FOR POPULATION ACTIVITIESSTARTS OPERATIONSThe Stonewall riots
in New York City
mark the start ofthe modern gay
rights movement in
the United States
First message sent
through ARPANET,a precursor to theInternet
Neil Armstrong
takes his historicfirst steps on
the Moon

NuclearNon-Proliferation
Treaty goes
into force▲
GENERAL ASSEMBLYDESIGNATES UNFPA
AS LEAD IN POPULATIONPROGRAMMES

▲

▲

▲

1969

1970

1971

▼

▼

▼

Biologist Robert
Geoffrey Edwards
reports having
fertilized humanoocytes in a
Petri dish forthe first time
USAID Officeof Population
established

Population Council
establishes theInternational
Committee forContraception
Research

Dalkon Shield IUD
goes on the market
Sierra Leone becomesa republicCity marked the start of the global
gay rights movement; the UnitedStates Agency for International
Development established an
Office of Population; and Ghana
adopted its policy for Population
Planning for National Progress andProsperity. A year earlier, at the

The United Statesand Soviet Union
join 70 other nations
in signing anagreement to ban
biological warfare

first United Nations International
Conference on Human Rights, inTehran, delegates had affirmed, forthe first time in a global declaration, the basic right of parents “todetermine freely and responsibly
the number and the spacing of theirchildren” (United Nations, 1968).

The bridge in Istanbulthat crosses the Bosphorus
is completed, connecting
the continents of Europe
and Asia▲WORLD
POPULATIONCONFERENCE,
BUCHAREST

By 1969, as a result of publichealth interventions that werereducing infant and child mortality
and prolonging life expectancy,
birth rates had outstrippedmortality rates in much of thedeveloping world. Concernsthat the resulting population▲
UNITED NATIONSDECLARES OPENING OF
DECADE FOR WOMEN

▲

▲

▲

▲

1972

1973

1974

1975

▼

▼

▼

▼

WORLD
POPULATION

Mozambique and Suriname
become independent

Club of Romereleases
Limits to Growth

THE UNITED
NATIONSPROCLAIMS
8 DECEMBER
INTERNATIONALHUMAN RIGHTSDAYThe American Psychiatric
Association removes
homosexuality from its
DSM-II
Abortion legalized in
the United States

4

Scientist Andrei Sakharov,creator of Soviet Union’shydrogen bomb, is awarded
Nobel Peace Prize

BILLION
India successfully conducts anunderground nuclear test

STAT E OF WOR L D POPUL AT I ON 2 01 9

9

growth could harm economic
progress and the environment
contributed to the desire to better
understand and manage human
fertility. The establishment of
the United Nations Fund forPopulation Activities, renamed
the United Nations Population

Fund in 1987, reflected a growinginterest in understanding how
population dynamics affectedsocial and economic development,
and a desire on the part of theUnited Nations to support action
programmes aimed at stabilizing
the world’s population.

The expanding availability ofrelatively new and effective contraceptive methods during the 1960s
was transformational for women,
offering them, for the first time,
the ability to reliably prevent unintended pregnancy and new choices
in controlling their reproductive

THE
STATE OF THE WORLD
POPULATION
1978

First known
outbreak ofEbola virus▲
THE CONVENTION ON THE ELIMINATIONOF ALL FORMS OF DISCRIMINATIONAGAINST WOMEN (CEDAW) IS ADOPTED

▲

▲

▲

▲

1976

1977

1978

1979

▼

▼

▼

▼

Egyptian
President
Anwar Sadat
makes anofficial visit
to Israel

10▲
UNFPA ISSUES FIRSTSTATE OF WORLD
POPULATION REPORTCHAPTER 1

First test tube baby bornFirst International Year of the Childlives. But the implications of contraception and fertility regulation
for the health, well-being and economic and social lives of individual
women and girls were only beginning to be understood. A fuller
realization of what they would
mean was still to come.

The world in 1994
Twenty-five years ago, when the
ICPD was held in Cairo, the average global fertility rate was about
three births per woman, and 58.8
per cent of women worldwide wereusing contraception; in the least
developed countries, fertility was

about 5.6 children, and 20.2 percent of married women were using
contraception. South Africa held its
first multiracial elections and elected Nelson Mandela as President;
the Rwandan genocide resulted in
the deaths of more than 800,000
men, women and children; civil

Sally Ride becomes the firstwoman in space aboard
Space Shuttle Challenger

UNITED NATIONS ESTABLISHESPOPULATION AWARD
▲

▲

▲

▲

1980

1981

1982

1983

▼

▼

▼

▼

Global eradicationof smallpox certified
by the World HealthOrganization

Sandra Day O'Connor takes herseat as the first female justice of
the US Supreme Court
China's population tops 1 billion
IBM puts its first personal computeron the market, launching operating
systems by Microsoft

Doctors performthe first implant of apermanent artificial
heart designed byRobert Jarvik

Retrovirus thatcauses AIDS
discovered
Famine in Ethiopia

Time magazine's
Man of the Yearis given for the
first time to a
non-human, thecomputer

STAT E OF WOR L D POPUL AT I ON 2 01 9

11

unions between same-sex partners
were legalized in Sweden; and thelaunch of America Online, or AOL,
marked the beginning of easy accessto the Internet.
The years preceding the ICPD saw
a gradual and accelerating shift: froma primary focus on population issues

and fertility reduction to one groundedin the rights of individuals and couples
to prevent or delay pregnancy andattain sexual and reproductive health.
This shift was largely driven by feminists and advocates for sexual andreproductive health and rights, andwas, in part, a response to the abus-

es that resulted from target-driven“population control” policies of thepast. In the 1970s and 1980s, withfunding and encouragement fromwealthy donor countries and foundations, some countries had rolled
out programmes that coerced orforced couples to use contraception▲▲
INTERNATIONALPOPULATION CONFERENCE,MEXICO CITY

Schengen Agreement
reached by fivemember States of theEuropean Economic
Community

DR. NAFIS SADIKNAMED UNFPAEXECUTIVE DIRECTOR
Space Shuttle Challenger
disintegrates, killing its
crew of seven

UNFPA NAME CHANGESTO UNITED NATIONSPOPULATION FUND

▲

▲

▲

▲

1984

1985

1986

1987

▼

▼

▼

▼

First embryo transfer fromone woman to another,resulting in a live birth

The US Food and Drug
Administration approves
a blood test for HIV
South Africa ends its ban
on interracial marriages

Corazon Aquino
becomes the first
Filipina woman
president
First child born to a
non-related surrogate
motherBlack Monday—stock markets
plunge on Wall Street andaround the world

WORLD
POPULATION

5BILLION
Safe Motherhood
Initiative
launchedor limit their family size, or provided monetary or other incentives toconvince them to do so.
The ICPD Programme of Action
adopted by 179 governments
called explicitly for dropping
demographic and fertility-control
targets from national population

First World AIDS
Day marked on
1 December

and family planning programmes.
While still acknowledging that
population dynamics meritedconsideration in policymaking,the Programme of Action issued
a clarion call to place women’s
needs and rights at the centreof population and development

Nelson Mandela isreleased from Victor
Verster Prison

policies. What the world needed,
governments agreed, was to provide
women, couples and families withaccess to a range of sexual andreproductive health interventions,and to realize social and economicchanges that would empower
women, respect their rights, and

Democratic People’s Republic of Korea and the Republicof Korea, Estonia, Latvia, Lithuania, the Marshall Islands
and Micronesia join the United Nations

▲

▲

▲

▲

▲

1988

1989

1990

1991

1992

▼

▼

▼

▼

▼

Berlin Wallis opened

Namibia becomes
independent
Destruction of
Berlin Wall begins

Croatia and Slovenia
declare independence from
Yugoslavia; the Balkans
war begins

Peace accord
in Mozambique

The Soviet Union dissolves

STAT E OF WOR L D POPUL AT I ON 2 01 9

13

help move the world towards
gender equality.

Advances and setbacks
since 1994
The ICPD consensus was aturning point, and a transformative
victory for the reproductive rights
movement.

▲
UNITEDNATIONS WORLDCONFERENCE ON
HUMAN RIGHTS

By placing individual rights
and well-being at the centre of
the reproductive health agenda,
it set in motion a number ofshifts: in research, to explore thefactors that influence individual
choices and behaviour in relation
to contraceptive use or non-use
and fertility; in communication, to▲
INTERNATIONALCONFERENCE ON
POPULATION AND
DEVELOPMENT, CAIRO▲THE UNITED NATIONSFOURTH WORLDCONFERENCE
ON WOMEN

Ghanaian diplomat Kofi Annanis elected as Secretary-Generalof the United Nations

▲

▲

▲

▲

1993

1994

1995

1996

▼

▼

▼

▼

The World HealthOrganization declares
tuberculosis a global
emergency

The Rwandan genocide
In South Africa,
Nelson Mandela isinaugurated president

More than 170 countries
agree to extend the
Nuclear Non-Proliferation
Treaty indefinitely andwithout conditions
The Dayton Agreement issigned in Paris to end war
in Bosnia
The Ebola virus kills 244
in Zaire14

inform and educate women, men
and decision makers about thehealth, economic and social benefitsof reducing fertility and preventing
unintended pregnancies; and inservice delivery, to underscore theimportance of providing a fullrange of contraceptive methods andensuring choices for all women.

CHAPTER 1

The Bosnian government declares
the end of the Siege of Sarajevo
Dolly the sheep, the first mammal
to be successfully cloned from anadult cell, is born

The ICPD also recognized thata woman’s sexual and reproductive
health and well-being encompass
not only her access to, and use of,contraception, but many otherfactors as well: her ability to preventand manage the complications of
unsafe abortion; her capacity to
avoid or treat sexually transmitted

infections, including HIV; and thecare she receives during pregnancy
and childbirth. Prevention andmanagement of infertility andreproductive tract cancers werealso defined as part of sexual andreproductive health.
The reproductive health needs ofadolescents, the ICPD Programmeof Action acknowledged, had been
largely ignored by existing services.
While the ICPD consensus called
for special efforts to address theseneeds, opposition to the provision ofcomprehensive sexuality education
and reproductive health services
to adolescents, and disagreementson the issue of parental approval,▲
Cathy O’Dowd, a South
African mountaineer,
becomes the first woman
to summit Mount Everest
from both the north andsouth sides

Divorcebecomes legal
in the Republicof Ireland▲
MILLENNIUM
DEVELOPMENTGOALSADOPTED▲
THORAYA AHMED
OBAID NAMEDUNFPA EXECUTIVEDIRECTOR

▲

▲

▲

▲

▲

1997

1998

1999

2000

2001

▼

▼

▼

▼

▼

The US House ofRepresentatives
forwards articles
of impeachment
against President
Clinton to the
US SenateWORLD
POPULATION

6BILLION

Historic summitof leaders of the
Republic of Korea
and the Democratic
People’s Republicof Korea

The world's first selfcontained artificial heart
is implanted in RobertTools in the UnitedStates
September 11 attacks at
the World Trade Centerin New York City

led to convoluted language in the
document and, in some cases, toconvoluted policies on the ground.
The ICPD coincided with the
crest of another public healthand rights crisis: the HIV/AIDS
epidemic. As concern and activism
about the enormous implicationsof HIV and AIDS ballooned,

some donors increased attention
and funding to addressing the
pandemic and its impact on people,
communities and nations, while
funding for other aspects of sexualand reproductive health remained
mostly stagnant.
Some observers feared that the
ICPD’s emphasis on individual

The Organisation of African Unity is disbanded
and replaced by the African Union

Brazil launches
its first rocket
into space

TARGET TO ACHIEVE
UNIVERSAL ACCESS TO
REPRODUCTIVE HEALTHAPPROVED FOR INCLUSIONIN MILLENNIUM
DEVELOPMENT GOALS

▲

▲

▲

▲

2002

2003

2004

2005

▼

▼

▼

▼

The Euro isofficiallyintroduced inEurozone countries

EARTH

SUMMIT

2002

16

choice and women’s empowerment
would not resonate with donors andgovernments, and that by moving
away from a focus on population
growth, the community wascompromising its ability to mobilize
resources and political commitment.
Despite such concerns, the ICPD
framework held. The commitment

CHAPTER 1

The Human Genome
Project is completed, with
99 per cent of the humangenome sequenced to99.9 per cent accuracy

European headsof State sign
the Treaty
and Final Act,
establishing thefirst European
Constitution

Angela Merkel, 51, becomes
Germany's first female chancellor,
and its youngest
Ellen Johnson Sirleaf becomes
first democratically elected
female head of State in Africa

to universal access to sexual andreproductive health was reaffirmed
in 1999 at the ICPD five-year
review meeting, where supporters
eked out advances on a few key
elements, including adolescentsexual and reproductive health, andaccess to safe abortion where legal,
in the face of fierce opposition.

In 2000, however, when the
United Nations adopted theMillennium Development Goals(MDGs) setting out global aims
and targets for the next 15 years,
reproductive health was nowhere to
be seen. Perhaps responding to thelength and contentiousness of thenegotiations at the Fourth World

Conference for Women in 1995
and at the ICPD five-year review
meeting in 1999, the officials
in charge of writing the MDGs
opted instead to define a goal on“improving maternal health.” Not
until 2005 did the sexual andreproductive health community
succeed in its quest to add universal

The Global
Programme
to Enhance
Reproductive
HealthCommodity
Security

1

UNITED NATIONSGENERALASSEMBLY VOTESTO ESTABLISH
THE UNITED
NATIONS HUMAN
RIGHTS COUNCIL

UNFPA LAUNCHESGLOBAL PROGRAMMETO ENHANCEREPRODUCTIVE HEALTHCOMMODITY SECURITY

Surgeons at London’s
Moorfields Eye
Hospital performthe first successful
operations using
bionic eyes,
implanting them into
two blind patients

Bolivia declares the rightof indigenous people togovern themselves

▲

▲

▲

▲

2006

2007

2008

2009

▼

▼

▼

▼

Michelle Bachelet
is sworn in as
Chile's first femalepresident

UNITED NATIONSGENERAL ASSEMBLYADOPTS THE DECLARATIONON THE RIGHTS OF
INDIGENOUS PEOPLES

The morning-after pill
approved by US Food andDrug Administration foruse by 17-year-olds

South Africa's
parliament passes
a law that legalizes
same-sex marriage

STAT E OF WOR L D POPUL AT I ON 2 01 9

17

access to sexual and reproductive
health as a target under thematernal health goal.
The initial omission of sexual and reproductive health from
the MDGs contributed to theperception that the issue was contentious and problematic, andtherefore easier to ignore, at leastin global discussions and negotiations. Despite frequently being
set aside by the global community,
funding and visibility for familyplanning continued, and at times
surged, receiving a strong boost
in July 2012 from a global Family
Planning Summit, which mobilized
major new donor and political

DR. BABATUNDE
OSOTIMEHINNAMED UNFPAEXECUTIVE
DIRECTOR

A new paradigm: 2015
and the Sustainable
Development Goals
In September 2015, 193 governments adopted a new global
framework to succeed the MDGs.

GENERALASSEMBLY ADOPTSRESOLUTION ON
PREVENTINGFEMALE GENITAL
MUTILATIONCOMMISSION ON THE
STATUS OF WOMEN CALLSON STATES TO END THE
PRACTICE OF CHILD, EARLYAND FORCED MARRIAGE

▲

▲

▲

▲

2010

2011

2012

2013

▼

▼

▼

▼

World HealthOrganization
declares theH1N1 influenza
pandemic overWORLD
POPULATION

7BILLION
The Syrian civil war begins

18

commitments and reinvigorated thefamily planning community.

CHAPTER 1

Typhoon Bopha hits
the Philippines

Beijing’s level of air pollution
is declared to be hazardous tohuman healthReflecting the expanded scope of theagenda and the growing complexityof the challenges to be addressed,
the 2030 Agenda for Sustainable
Development includes 17 Sustainable
Development Goals (SDGs) with
169 targets. While the number andproportion of people living in poverty
declined between 2000 and 2015,

20-YEAR REVIEWOF PROGRESS
IMPLEMENTING ICPD
PROGRAMME OF
ACTIONeliminating poverty remains the overriding aim of the new global agenda.
But there are new aspects to oldchallenges, as well as new challenges, that are explicitly acknowledged
and targeted in the SDGs. These
include climate change and environmental fragility; a growing
number of intractable humanitarian

SUSTAINABLE DEVELOPMENTGOALS ADOPTED, INCLUDING
UNIVERSAL ACCESS TOSEXUAL AND REPRODUCTIVE
HEALTH CARE AND SERVICES

and political crises, and a consequent increase in the number ofpeople living in fragile and unstablesettings; and a greater emphasis on
the need for domestic financing aswell as development aid to build
resilience, expand capacity andestablish the basis for sustainableeconomic and social progress.

World Health Organization
announces an outbreak of the
Zika virus

▲

▲

▲

2014

2015

2016

▼

▼

▼

Ebola epidemic in West Africa
infects at least 28,616 people
and kills at least 11,310 people

World leaders gather in Paris forhistoric climate change talks

276 girls and women in Nigeria
are abducted and held hostage

STAT E OF WOR L D POPUL AT I ON 2 01 9

19

Unlike the MDGs, the SDGs
explicitly recognize sexual andreproductive health as essential toequitable development and women’s
empowerment, referencing sexualand reproductive health under
SDG 3, for health, and again under
SDG 5, for gender equality, which
also references reproductive rights.

As was the case with the ICPD andthe MDGs, however, the SDGs
do not acknowledge sexual rights.
Other central elements of sexualand reproductive health, including
maternal and newborn mortality
and HIV, were addressed undertargets for SDG 3, and gender-based
violence and harmful practices under

DR. NATALIA KANEMAPPOINTED UNFPAEXECUTIVE DIRECTOR

targets for SDG 5. The SDGs also
call for achieving universal healthcoverage, specifically by ensuring
access to quality essential health-careservices and to safe, effective andaffordable medicines and vaccines forall. Overall, the SDGs advance anagenda for all people, as the ICPD
continues to do, while emphasizing

UNFPA TURNS 50

▲

▲

▲

2017

2018

2019

▼

▼

▼

Millions of people in
168 countries join the
Women's MarchThe United Nations warns
that 20 million people
are at risk of starvationand famine in
Yemen, Somalia,
South Sudan
and Nigeria

Global Conference on
Primary Health Caredeclares central role forsexual and reproductive
health25TH ANNIVERSARY
OF THE ICPD

ICPD25International Conference on

Population and Development

20

CHAPTER 1

the importance of equity andaddressing the needs of the mostvulnerable.
Over the past 25 years, in various
review meetings and processes
related to the ICPD, someregions of the world have called
for recognition of sexual rights.
A number of current definitionsof sexual rights, including thosepresented in the 2018 report of the
Guttmacher-Lancet Commission
on sexual and reproductive healthand rights, and by the World
Health Organization, encompass
the rights of people to express
their individual sexuality; therights of adolescents to receive
comprehensive sexuality educationand sexual and reproductive healthservices; and the rights of womenand girls to be free of genderbased violence and coercion.
These rights have been recognizedand endorsed by civil society
organizations around the world,
and acknowledged in various
regional documents negotiatedand endorsed by governments. No
consensus on these rights, however,has been reached by all the Member
States of the United Nations in any
globally negotiated document.

sexual and reproductive health andrights, and to reaching those whohave been left behind. This agenda
must pay attention to population
dynamics, recognize the diverse
challenges faced by different
countries at various stages ofdevelopment, and ground policies
and programmes in respect for, andfulfilment of, human rights and the
dignity of the individual.
There is enormous momentum
around efforts to achieve the SDGs,
including a renewed commitment
to “health for all,” explicitly
recognizing that every humanbeing has a fundamental rightto the enjoyment of the highest
attainable standard of health,without distinction. The Every

Woman Every Child movement,
launched by former United Nations
Secretary-General Ban Ki-moon
in 2010 and now led by SecretaryGeneral António Guterres, brings
concerted attention and effort to
the SDGs and universal healthcoverage as they relate to women,
girls and adolescents, with sexualand reproductive health and rights
as one of its key focus areas.
The pursuit of rights andchoices for all is an ongoing one,with new challenges emerging
all the time. Over the years,
the nature and scope of theseobstacles may have changed, but
the international community’scommitment to overcoming themremains strong.

2019 and beyond
UNFPA’s 50th anniversary and
ICPD’s 25th anniversary present aunique opportunity for the global
community to build on the ICPD
framework and fully commit torealizing a visionary agenda for

Millions of women in India join hands to form a 385-mile wall to protest
inequality, 2019. © Babus Panachmoodu

STAT E OF WOR L D POPUL AT I ON 2 01 9

21

© UNFPA/R. Anis

CHAPTER 2

SIX WOMEN,SIX DECADES,SIX JOURNEYS
Six women who were 10 years old in 1969, when UNFPA wasestablished, and 35 at the time of the International Conference on
Population and Development, reflect on marriage, work and family.
Did they have the freedom to choose their own paths and shape
their own futures?

STAT E OF WOR L D POPUL AT I ON 2 01 9

23

© UNFPA/R. Anis

Choices werelimitedDahab Elsayed, 60, lives in a
marginal neighbourhood of
Cairo. She vaguely remembers
the excitement in her city whenthe International Conference on
Population and Development(ICPD) took place. But because
she was busy working and caring
for her family back then, details
about the conference and its
impact eluded her.
But some of the shifts in attitudes
about women and girls she
witnessed later in life can be traced

24

CHAPTER 2“There were no opportunities otherthan marriage—it was the only
future I could foresee.”Dahab
to the ICPD, which acknowledgedthat fulfilling the rights of girls andwomen, especially their sexual andreproductive choices, is central todevelopment.
As a girl, growing up in a poor
rural family of 15, Dahab’s
choices were limited, and even an
education was out of reach. “There

were no opportunities other thanmarriage—it was the only future
I could foresee,” she says.
Dahab recalls the day that awoman came to her house andcut her genitals. Dahab had no
idea what was happening, but
recalls the pain, the blood, andthe powder that was appliedto staunch the bleeding. She
remembers staying in bed for
15 days to heal. But when she
grew older and started a familyof her own, she had her own
daughter’s genitals cut. “It[female genital mutilation] was amust,” Dahab says. Her in-laws
insisted on it. Marriage prospects
depended on it. All the girls were
cut back then.
She now believes it is wrong tobe subjected to this practice,and her granddaughter has beenspared. “Now it is not preferable,”says Dahab, who learned froma television campaign about theharm female genital mutilation
causes, and the fact that theprocedure is now illegal.
Dahab had four children inquick succession soon after her© UNFPA/R. Anismarriage. Faced with poverty, andher husband’s declining health,
the couple decided they had
enough children. Because shealways did odd jobs—cleaning,
laundry, caretaking—she never
had health insurance to pay forcontraception. But intrauterine
devices were subsidized in Egypt,
so she started using one.

she would probably use it toearn more money. Soon she
will receive a small government
pension, but it will not beenough to support her, so
she will continue to work.
“Women are the ones thatwork and get the money
for the family,” she says
matter-of-factly.

Her husband, an upholsterer,
died 20 years ago. Since then, it
has been increasingly difficult forher to make ends meet. Threeof her children have medical
conditions that prevent themfrom working. To help support
them, and herself, she works at
two jobs during the day and cares
for an older person at night. She
rarely even goes home. Much as
she would like to learn to read
and write, if she had more time,

As Dahab and other 60-yearolds share glimpses of theirlives, their dreams andstruggles, it becomes apparent
how deeply the political andeconomic circumstances they
were born into delineated thecourse of their lives. Althoughreal choices and options werelimited, most of the womenfound ways to navigate
within them, carving out
meaningful lives.

The lives and experiences of thewomen turned out to be very
different from what each hadenvisioned for herself at age 10.
Sometimes aspirations were
circumscribed by the limitedroles that seemed available
to females at the time. Other
times, they were thwarted bysocial upheaval. Some lives
took unexpected turns, andwere successful in ways their
10-year-old selves could nothave imagined.
But across their disparate
journeys, common threads
emerge, many of them directly
related to the mandate andwork of UNFPA.

Facing a world oflimited horizons
Rajeshwari Mahalingam recalls
enjoying school in the IndianState of Tamil Nadu, where she
was known for her beautiful long
curly hair and her participationin dance performances. But noone ever asked her about her
dreams or what she would like to
do in the future. When she did
think about it, her possible roles
seemed limited: homemaker,
medical worker, teacher.

26

CHAPTER 2

She entered into an arranged
marriage at age 25. She wasobliged to wait until all seven ofher older siblings were married
and her parents were able to find
an appropriate match, one that
did not require an exorbitant
dowry.

After giving birth to two children
through caesarean sections, she
was told that future deliveries
would have to be caesareans as
well, and the cost would have been
more than her family could haveafforded, so she decided to have atubal ligation. She had already hadto sell some of her gold jewellery
to pay for the delivery of her
second child, a daughter.
Most of her friends at that time
were having smaller families.
They were influenced by familyplanning campaigns, Rajeshwari
says, recalling the popularslogan: “A planned family is a
happy family.”© UNFPA/S. Clicks

She devoted most of her life tocaring for her family, although
she did take in and care forother children for extra money
when times were tough. She
invested most of her energy andher dreams in her two children,
who are now both collegeeducated and successful. “I told

© UNFPA/Stormy Clicks© UNFPA/Stormy Clicks“I enjoyed motherhood
more thananything else.”
Rajeshwari

them stories and read books withemphasis on service and being
honest human beings. I longed tosee them grow and reach higher,”she says.
“I enjoyed motherhood more thananything else. A woman is the lightof the house,” Rajeshwari says.
“A woman contributes to thefamily, in that way, to thecommunity, country and world.”
Over her lifetime, Rajeshwari
witnessed big changes in the
expectations and possibilities foryoung women. Before she wasmarried, she was afraid to do muchoutside the home—her parents
did not approve. But her sister,
just five years her junior, enjoyed agreater sense of personal freedom,which allowed her to become asocial activist, achieve a master’s
degree, and work professionallyon women’s issues.

From deprivation topolitical action

early in her marriage, during
which she raised six children,
fetched water from a source akilometre and a half away, andtended her cows. “I managed
to sell some milk to get a little
money to buy a few things
at home.”As a 10-year-old in Uganda,
Josephine Kasya admired herteachers: “They were the smartest
people—and I said I will become ateacher. Also my dad was a teacher,and I liked him so much. I said,‘I want to be like my dad.’”But she does not regret those earlystruggles, she says, because theygalvanized her into action. “It isout of that rural set-up that
I started convincing women tocome together and pool their

But when Josephine was 12, Idi
Amin seized power in her country,
and years of instability, deprivationand violence followed. Her dreamof becoming a teacher nevermaterialized.
After a civil war that ended in
1986, so much of her community
was destroyed or lost that she
and her new husband, a social
worker, moved to his somewhat
remote homeland in a verdant,southern part of the country.
While less affected by the war, her
new community lacked the social
infrastructure she was used to.
“Life became very different anddifficult,” she says of that period

28

CHAPTER 2© UNFPA/M. Mugisha

resources.” There too she learned
how to partner with otherorganizations to get things done.
Her leadership skills were noticed,
and she was elected to lead, firstat a more local level, and later,in 2001, as the Chairperson of“I demystified the idea that the position
was entirely for males and paved theway for other women to take on similar
positions in other districts.”
Josephine© UNFPA/M. Mugisha

a district comprising 250,000
people. Throughout her politicalcareer, she has championed
community development,
education for girls and genderequality, focusing on being avoice for rural women. She
became the first woman
District Chairperson in Uganda.
“I demystified the idea thatthe position was entirely formales and paved the way forother women to take on similar
positions in other districts,”
she says proudly, adding thatin her district a number ofother women have taken on
decision-making roles.
© UNFPA/M. Kasztelan

When war subverts
choices
Say Yang dreamed of going toa good school, studying hardto fulfil her wish to becomea teacher. But her dream
evaporated when she was
16: soldiers appeared in her
community, firing in the airand shouting. She was separated
from her family and forced to
do backbreaking work. “Wardestroyed everything,” she says.
“Even my dreams. Indeed,
I didn’t dare make a dream.
During a war, people don’t have

“During a war, people don’t haveeven a choice to choose. They dowhatever they can to survive.”
Yang
even a choice to choose. They dowhatever they can to survive.”
In Cambodia, when personal
freedoms were curtailed under the
Khmer Rouge, Yang was forced

to marry someone whose nameshe did not even know in a large
collective ceremony. As theirnames were called out, eachcouple came forward. They held

STAT E OF WOR L D POPUL AT I ON 2 01 9

29

Championing the rights
of women
Until Alma Odette Chacón was
14 years old, she led a relatively
uneventful, happy life as theeldest of six children in a family
in Guatemala City. Her parents
prized education and sent thechildren to a Jesuit school.
When she thought about the
future, Alma imagined being ateacher like her mother, or an
accountant like her father. Whatshe knew for sure was that she
wanted to help others.

© UNFPA/M. Kasztelanhands and promised to live ashusband and wife. Initially, andfor several months, she and herhusband were so shy that theyrarely dared to look directly at ortalk to each other.
When rule by the Khmer Rouge
ended, Yang and her husband
travelled back to her home town
to live with her mother. Between
1981 and 1988, she delivered
five children, with one dying ininfancy and another at age 13.
After learning from a neighbour

30

CHAPTER 2

that the hospital in the next town
would perform a tubal ligation, shemade the arduous and somewhat
perilous journey to take advantage
of it.
One day in Cambodia, Yang
got the good news that she wasinvited to enrol in teacher training.
“However, I just could not makeit. I had a child to look after andhousework to handle from day today. I let my husband go instead.
We had to balance between family
and society.”

Her life changed abruptly thenight her mother went to thehospital to deliver her seventhchild. She never returned. Even
though all her mother’s priordeliveries had been normal, thistime something went wrong.
Alma’s world fell apart. “Itwas very difficult,” she says.
“Suddenly you are missing the
key piece of the family, witheach person going his or her own
way.” Before her mother’s death,
Alma had always been at the topof her class, but now couldn’t
keep up her good grades. Her
father was absent much of
the time, and eventually her

stepmother threw her out of thehouse.

the plight of the dislocated, Almafound herself helping survivors.

A year after Alma’s mother died, a
7.5 magnitude earthquake killed
or injured 100,000 people near
Guatemala City and displaced
more than 1 million. Sensitive toSoon after, she was sponsoredby her school to spend a monthteaching in an indigenous
Quiché community. Those
two experiences dealing with

© UNFPA/Rizzo Producciones

marginalized and suffering
people—mostly indigenous
women—were central to her
lifelong commitment to social
justice, she says.
In her 20s, fearing arrest forher involvement in politics,
she left Guatemala for Mexico,
where she sought training incommunications. There, she saw afreer way of living and was exposedto feminist ideas. To support
herself, she worked in a variety ofjobs: cleaning, production assistantand secretary to a centre for humanrights, among other things.

“Women now
clearly know they
have rights andthey should be able
to decide whatgoes on with
their bodies.”
Alma

STAT E OF WOR L D POPUL AT I ON 2 01 9

31

In the mid-1990s, Alma travelledaround Central America andhelped organize a regional meetingon the rights of women. This
work galvanized her engagementin the women’s movement andher understanding of sexual andreproductive health and rights
as a central lever to broader
development.
She is again living in Guatemala
and has worked for several decades
now with Terra Viva, a non-profit
organization that addresses theseissues. Through this lens, she sees
big changes in the attitudes ofwomen, especially in indigenous
communities: “Women now
clearly know they have rights andthey should be able to decide whatgoes on with their bodies.”

A lifetime of helping
othersTefta Shakaj always wanted to
study at university to become adoctor, but that was not an option
for her in Albania when she wasa teenager. “We were obliged
to do what we were told,” shesays. After completing secondary
school, however, she did get an
opportunity that changed thecourse of her life: a one-year study
programme to become a nurse
midwife.
After her training, Tefta was
assigned to a remote village thatlacked medical facilities, personnel
and supplies. Life there was toughon many levels. But she loved
caring for newborns and mothers
and served with passion—© UNFPA/Rizzo Producciones© UNFPA/G. Banaj

delivering babies, providing
antenatal care, attending to young
children in a paediatric ward. “Ihave helped a lot because many
deliveries took place at home—
there were not many centres. I am
happy I helped so many women.”In the early 1990s, following thefall of Albania’s communist regime,
she lived through chaos andshortages of everything, she says.
She married and had two children,
but would have had more if there
had not been so much economic
uncertainty at the time. Then, too,her husband got sick, and they32

CHAPTER 2

“I am happy
I helped somany women.”Tefta

needed money for medical services.
Unable to access contraceptives,
she became pregnant, and likemany women of that era in Eastern
Europe, she had an abortion.
There was a positive side to theturmoil of the early 1990s, shesays: it spurred an exodus of
Albanians to Italy and Greece,
exposing people to new ideas andways of doing things. From those
who left Albania, “we started
to see another world and otherperspectives,” she says. “Before that
we had only heard that everythingoutside Albania was bad.”Life is improving in Albania,
Tefta says, and she believes
that her own daughters andgrandchildren will have morechoices and opportunities than she
had. For one thing, contraceptives© UNFPA/G. Banaj

are now widely available and free.
And for another, her younger
daughter has chosen to becomea police officer—a sign that old
notions of gender equality arechanging.

© UNFPA/R. Anis

The lives they lived
All six women are remarkable in
the impact they have had on others,
whether in their own families orin a wider sphere. But when theirlives are viewed across a span of six
decades it is also clear the extent towhich the women, several of them
powerful agents of change in theirown families or communities, werealso very much affected by larger© UNFPA/Stormy Clicks

34

CHAPTER 2© UNFPA/M. Kasztelansocial, political and economic
forces. Compromises were made;aspirations thwarted.

unlived dreams for education
are being fulfilled through her
children.

Dahab continues to toil at threejobs, but she says she has accepted
her life, and feels content.

Although Yang says her dreams
died with the violence she endured
during wartime, her close family
relationships are central to herlife. In addition to caring for her
four grandchildren and, fromtime to time, her ageing mother,

Rajeshwari’s early love of dance
has transformed into her training
in a rigorous form of yoga. Her

© UNFPA/G. Banaj

she recently started up a familylaundry business.
Alma continues to find meaningand purpose in her work on
women’s empowerment, with noplans to retire soon. “There ismore to come,” she says.
Tefta, who has been struggling
with cancer, is determined to see

her granddaughter grow up andto stay engaged in life. “I won’t
let the tumour get the best ofme,” she says. “I’ll continue tohelp as long as I have energy.”

what she loves. “As years go
by, I’m not as strong as I used
to be. But I’m very passionate
about baking and am planningto train a group of women sothey can bake and sell bread.”

And Josephine in Uganda
intends to run for one moreterm—her fifth—before retiringfrom public office. But she is
not planning to stop doing© UNFPA/M. Mugisha© UNFPA/Rizzo Producciones

Upbeat population image still searching© UNFPA/Photographer© UN Photo/ILO

CHAPTER 3

RIGHTS AT RISKIN TIMES OF
POPULATION GROWTH
It was an era of extraordinary technological advances.
Neil A. Armstrong and Edwin Aldrin, Jr., took the first walk on
the moon in 1969. Also that year, for the first time, doctors
replaced a dying man’s heart with a mechanical one. And a humanegg was fertilized in a test tube (Edwards and others, 1969).

And by 1969, earlier advances inmedical technology, along withstronger public health systems,
better nutrition and sanitation,
and a global commitment toending the scourge of infant andchild mortality, had started paying
off. Worldwide, child death rates
plummeted from 215 deaths per
1,000 live births in 1950 to under
160 per 1,000 just 19 years later(United Nations, 2017).
Other medical advances were
helping people to live longer.

Worldwide, life expectancy in1969 was about 55 years, up from47 years in 1950.
Improved child survival rates
and longer lives transformed thehuman condition. But whencombined with a global average
fertility rate of about five births
per woman, they also changed theworld’s population trajectory.
The world’s population in 1969
was growing at about 2 per cent a
year. At that rate, world population
would double in just 35 years.

Never before had population grown
so rapidly.

From celebration
to concern
Global celebration of public healthsuccesses soon gave way to fears
of a dystopian future in which
too many people competed forever-dwindling resources. Whatwould such growth mean for global
challenges like hunger? What would
it mean for areas that were torn
by conflict? How could efforts to

STAT E OF WOR L D POPUL AT I ON 2 01 9

37

grow economies and bring people
out of poverty keep up whenhuman numbers were expanding so
dramatically? And what could bedone about it?
To some, population growth
was seen not as a reflection ofhuman progress but as a threat tohumanity, a problem that required
an urgent solution.
Fears of the consequences of
rapid population growth gripped
the security community as early as
the 1950s. In the United States,
President Dwight D. Eisenhower
designated retired general William
H. Draper to lead a committee
to devise coherent strategies fordevelopment assistance. Draper’s
committee flagged what it saw
as major concerns related topopulation growth in various partsof the developing world, primarily
linked to food production.
“Problems connected with world
population growth will be among
the most serious to be faced by
the younger generation of today,”the committee’s 1959 report read.
“Unless the relationship between
the present trends of population
growth and food production isreversed, the already difficult task of
economic development will becomea practical impossibility” (Draperand others, 1959).
To address this challenge, thecommittee recommended that theUnited States and other advanced
economies provide information andtechnical assistance to developing

38

CHAPTER 3

Worldwide, child death rates
plummeted from 215 deaths
per 1,000 live births in 1950
to under 160 per 1,000
just 19 years later
215
160

1950

1969

“Problems connectedwith world
population growth
will be among themost serious to be
faced by the younger
generation of today.”
Draper Committee

countries, at their request, “inthe formulation of their plans
to deal with the problem of
rapid population growth.” It also
recommended that the UnitedStates “increase its assistance tolocal programs relating to maternaland child welfare.”Several years later, Paul Ehrlich
opined in The Population Bombthat “Whatever problem you’reinterested in, you’re not going tosolve it unless you also solve thepopulation problem. Whatever
your cause, it’s a lost cause without
population control” (Ehrlich,© Mark Tuschman1968). Ehrlich was interviewed
numerous times by Johnny Carson,
the host of the popular American
late-night television programme
The Tonight Show. The bookbecame a bestseller, and soon thenotion of “overpopulation” andquestions about what, if anything,should be done about it were being
debated in living rooms, lecturehalls and the halls of government
worldwide.
A 1972 study commissioned byinternational think tank the Club ofRome and carried out by researchersat the Massachusetts Institute ofTechnology further heightened
concerns about what continued
rapid population growth could
mean for society. In their study,
The Limits to Growth, the researchers
elaborated future scenarios basedon differing assumptions related
to population growth, foodproduction, industrialization,
pollution and consumption of
non-renewable natural resources(Meadows and others, 1972).
The “standard run” model, which
was based on a continuation ofhistoric trends from 1900 to 1970,
led to “overshoot and collapse,”

stemming from resource depletion,
the collapse of the industrial base(and with it agricultural systems,
which have become dependent on
industrial inputs), and population
growth that is eventually reversed
due to increasing death rates fromlack of food and health services.
Other scenarios based on tweaked
assumptions about one or morevariables also led to eventual
overshoot and collapse. Only one
scenario, in which populationand industrial capital growth rates
stabilize and technological advances
support pollution control and

STAT E OF WOR L D POPUL AT I ON 2 01 939

efficient food production, achieveda state of equilibrium that resulted
in a “stabilized world.”“If the present growth trends inworld population, industrialization,
pollution, food production andresource depletion continue
unchanged,” the researchersconcluded, “the limits to growth on
this planet will be reached sometime
within the next 100 years. The
most probable result will be a rather
sudden and uncontrollable decline
in both population and industrial

capacity.” The methods and results ofthe study were widely discussed anddebated, spawning further interest in
examining the interactions between
population growth and other humanand natural systems (Nørgård andothers, 2010).

From concern to control
Fearing that rapid population
growth would reverse development
gains, spawn famines, or worse,international and non-governmental organizations and individual

governments began to take action.
In many places, this action was in
the form of examining population
trends and seeking to better
understand their implications forother societal goals. In other places,
action took the form of launchingfamily planning programmes. In
some places, action resulted in steps
to encourage—or even force—
couples and individuals to havefewer or no children, sometimes
infringing on rights and choices
along the way.

Family planning mural: “Second child after three years,” India, 1988. © Raghu Rai/Magnum Photos

Throughout the 1970s and1980s, many countries adopted
population or family planningpolicies. Often, such policies
contained goals or targets linked todemographic outcomes—a target
date for achieving population
stabilization, for example, or goals
related to reduction in fertility rates
or increase in the proportion of the
population using a modern methodof contraception.
Demographic objectives, however,sometimes took precedence overindividual rights and choices. Familyplanning programmes that were
voluntary, where individuals had thepower to make their own decisions
about contraception, were seen
by some as inadequate to reduce
fertility. “The conditions that cause
births to be wanted or unwanted
are beyond the control of familyplanning, hence beyond the control
of any nation that relies on familyplanning alone as its population
policy,” wrote American sociologist
Kingsley Davis in an influential
article in 1967 (Davis, 1967). He
argued that if population policy weremeant to control population growth
to the benefit of society, then new
directions in population policy—
beyond simply providing familyplanning—would be needed.
Among Davis’ recommendations:the postponement of marriage, as
well as interventions to encourage
the limitation of births within
marriage. Such interventions
had the potential to erode theFree child care service offered by family planning programme. India, 1972.
© UN Photo/ILO

protection and promotion ofindividual rights. For example,
financial incentives—such as cash
payments, food or household
items—were incorporated intosome population policies as a
strategy to persuade couples toadopt particular family planning
methods or limit childbearing(Heil and others, 2012); some
population policies also offeredhousing and lending preferences
to families with fewer children(Ross and Isaacs, 1988).

Goals to reduce fertility andslow population growth have,in a number of cases, interferedwith individual rights and choices
as outlined in the Programmeof Action of the International
Conference on Population andDevelopment (ICPD). The familyplanning policy of China, forexample, generally limited couples
to one child. This policy was
enforced, while it wasin effect from 1979 to 2015,
through an array of penalties

STAT E OF WOR L D POPUL AT I ON 2 01 9

41

Expanding understandingof trends, enhancing
options for individuals

A young woman examines the “loop” at a family planning centre. East Africa, 1973.
© UN Photo/FAO

and mandated contraception,abortion and sterilization (Wangand others, 2016).
Demographic concerns drove
many of the innovations incontraceptive technologies in
the 1950s and 1960s, leading
to modern methods including
oral contraceptives, intrauterine
devices and injectables. But insome cases, demographicallymotivated population policies led toapproaches that limited quality ofcare and jeopardized the health andrights of individuals.
The first large-scale test oforal contraceptives, for example,

42

CHAPTER 3

took place in 1956 among 200
women living in a housing projectin Puerto Rico. The women
were given little information
about safety and potential side
effects, as little was known at thetime (Liao and Dollin, 2012).
Over time, other concerns havebeen raised about the practicesof agencies, private companies
and governments responsiblefor developing and evaluating
contraceptive technologies—
including concerns about lackof informed consent, adequate
counselling and medical follow-up(United Nations, 2014).

While population growth fears led
in a number of cases to policies andprogrammes that limited or eventrampled on rights and choices,the demographic shifts of thetwentieth century also inspired newwaves of scholarship and global
discourse on the ways in which
population dynamics influence andare influenced by socioeconomic
trends, and how these trends
intersected with an emerging
human rights agenda.
New institutions emerged toinvestigate the implications of
population growth and potential
policy and programmatic responses.
In 1952, John D. Rockefeller
III convened a meeting under
the auspices of the United States
National Academy of Sciences
to investigate questions related
to demographic trends and theirconsequences. Not long after,
he established the Population
Council to continue this work.
From its early days, the Population
Council engaged in pursuits
related to building understandingof population trends and theirrelation to societal goals: one of its
first programmes provided support
to graduate students for advanced
training in demography.
The early work of the
Population Council was not
purely demographic, however; itPopulation growth and economic growth
After an initial grounding in ideological debates,
evidence—not political power and support—
would be brought to bear on the question of how
economic and population growth were related.
An important paper by Coale and Hoover (1958)
demonstrated that across countries where
population growth was very high, economic growth
lagged. This correlation did not demonstratecausality, but it was nevertheless used by someto buttress fears of high population growth rates’
negative impact on economies.

old and very young. If this period coincides with abroad-based and significant investment in humancapital concentrated from youth to adulthood,along with opportunities in the labour market, theresult is a boost in economic growth and prosperity
for the population. This effect, referred to as the“demographic dividend” or “demographic bonus,”
does not last indefinitely. As mortality continues
to fall, including at older ages, elder dependents
become an increasing proportion of the populationand the opportunity for a dividend may
be attenuated.

This effect,referred
to as the“demographic
dividend”
or“demographic
bonus,“
does not lastindefinitely

Later studies debunked that notion,
however. For example, in 1984, shortly
before the International Population
Conference in Mexico City, a study
commissioned by the United States
National
Academyof
Sciences
concluded that population growth was aneutral factor in economic growth. Thisconclusion came from a comparison of
growth rates in population with growth
rates in the economy (not in levels of thetwo). There seemed to be no relation(National Research Council, 1986). This
uncertain conclusion and other researchreinforced resistance to family planning
efforts, at the 1984 conference and beyond.

Since the late 1990s, there has been growing
recognition that total aggregate population levels
and change do not provide an explanation of therelationship. What is critical is the change in theage structure of populations as births are fewer,
later and safer (Bloom and others, 2000 and2007; Bloom and Canning, 2004), together withthe attributes and opportunities of the population,
specifically around education (Lutz and others,2008), health and employment (Joshi and Schultz,
2007). As fertility declines, the proportion of the
population that is of working age increases relative
to the proportion of the population that is very

With growing scholarship on the
demographic dividend, population
dynamics has re-earned its placein economic policy discussions.
This re-emergence has not been
free of additional caveats andmisunderstandings. The phenomenon
is associated with a larger populationof youth and adults relative to children
and older people, not a raw increasein this working age population—so it
requires a decline in fertility to reduce
the size of following cohorts. Genderissues also need to be included.
Working populations increase when women can
productively enter the labour force (the same istrue of marginalized and excluded populations).
Further, ageing is not always associated with a lost
window of opportunity. People are born without
resources but enter old-age “dependency” withaccumulated resources, unless they have been
perennially poor. The window of opportunity isalso often wrongly assumed to dissipate quickly
when dependency reaches its minimum, eventhough it will still be more favourable than theinitial starting point for additional years. This fact
reinforces the need for supportive investments
over time, initially facilitating and then maintaining
the dividend.

STAT E OF WOR L D POPUL AT I ON 2 01 943

also reflected an understandingthat demographic trends had
individual lives at their foundation.
Population Council programmesin social and biomedical researchsought to illuminate the context inwhich individuals made decisions
about their reproductive lives,
and to investigate contraceptive
technologies that could help to
expand individuals’ options related
to sex and childbearing. Theseissues were of central concern tothose working to expand women’s
options and choices within
what was known at the time as
the “birth control” movement;
indeed, the International Planned
Parenthood Federation wasestablished in the same year,
under the joint presidency of birthcontrol pioneer Margaret Sanger of
the United States and Lady Rama
Rau of India (Claeys, 2010).

Margaret
Sanger© Pictorial Press Ltd/Alamy Stock Photo

44

CHAPTER 3

The Draper Committee’s 1959
report was influential in theeventual establishment of the
Office of Population at the UnitedStates Agency for International
Development in 1969, and otherdeveloped countries began toestablish population programmes
as part of their foreign aid
strategies. The key feature of these
programmes was the provisionof family planning informationand services. The United Statesand Sweden soon became leadingbilateral donors for family planning
programmes throughout thedeveloping world (Robinson andRoss, 2007).
Concerns about rapid population
growth also found their way into theUnited Nations General Assembly,
which in 1966 passed resolution
2211 (XXI), titled Population
growth and economic development.
This resolution called on the
United Nations “to assist, whenrequested, in further developing andstrengthening national and regional
facilities for training, research,
information and advisory services in
the field of population, bearing in
mind the different character of the
population problem in each country
and region and the needs arising
therefrom” (Singh, 2002). The
next year, Secretary-General
U Thant established a trust fundwith a broad mandate to support
the development of population
policy in countries around theworld, and in 1969, that trust fundbecame UNFPA, with Rafael Salas
as its first Executive Director.
UNFPA, along with its peer
institutions of that era, helped
to launch deeper inquiry into
the causes and consequences of
population trends. In partnershipwith the United States Agency
for International Development,
UNFPA launched the World
Fertility Survey to gather andsynthesize robust population data.
This survey, for the first time,helped to shed light on importantquestions related to women’s lives—
including their preferences, choices
and needs related to fertility andchildbearing.
The Population Council,
International Planned Parenthood
Federation, United States Agency
for International Development andothers were founding members of anew population movement, whichbrought new energy, political will
and resources into the explorationof population questions, resulting
in the expansion of family planning
programmes in the developingworld that helped empower
individuals to make choices about
their reproductive lives. There was,however, growing tension within
the movement about whether
population growth, at its root, wasa problem; and if it was, whether
family planning programmes werean appropriate or sufficient solution.
This tension came to the fore atthe World Population Conferencein Bucharest in 1974. By that time,

CHAMPION OF CHANGE
Known affectionately as “Mr. Population,” Rafael Salas
oversaw the birth of UNFPA as its first Executive Director in1969. Under his leadership, UNFPA grew from a minor bodyto the world’s largest multilateral provider of population
assistance. Along the way, global consensus emerged around the integral links between population anddevelopment and people’s sexual, reproductive and health rights, culminating in the Programme of Actionof the International Conference on Population and Development.

Rafael Salas“Parents have a basic human right to determine freely and responsibly the number and the spacing of
their children,” he told participants in the 1968 International Conference on Human Rights. It was a novel
statement for the time, especially in Salas’ role as conference vice-president.
Salas was widely known for bringing together people who might otherwise remain apart, helping themmove past fixed positions of ideology and agree on common concerns. Always, the focus was on realizing
the greater good. He led the 1984 International Population Conference in Mexico City and pioneered thework of the United Nations with parliamentarians and religious leaders. He persuaded people at all levelsof government to introduce population and poverty links into national development plans.
A man of many talents, Salas was at different points a professor and a poet, the Executive Director of
the National Economic Council in his native Philippines, and the general manager of The Manila Chronicle.
As national coordinator of the Philippine National Rice and Corn Sufficiency Program, he jump-started a“green revolution” that for the first time made the Philippines self-sufficient in rice production.
In 1987, after his tenure as Executive Director of UNFPA wascut short by his untimely death, friends and colleagues gatheredfrom all corners of the globe to say goodbye. As his many
achievements were lauded, they agreed they had lost a greatman, yet one who had always carried himself as a humble
public servant. For his humanity and years of service, hewould be remembered as dearly loved.

“Parents have a basic human right todetermine freely and responsibly the
number and the spacing of their children.”© UN Photo/Milton Grant

STAT E OF WOR L D POPUL AT I ON 2 01 945

developed countries had alreadybeen supporting family planning
efforts in developing countries
and assisting governments inestablishing population policies.
However, not all developing
countries welcomed that support;
some, in fact, did not see
population growth as a challenge intheir countries, and were frustrated
that the developed world was,by their way of thinking, unduly
distracted by the issue. For those
whose views were influenced

by a Marxist labour theory ofvalue, a larger population meant
more labourers and therefore thegeneration of greater wealth—andattempts to blunt that growth were
met with suspicion and resistance.
Others believed that more labourers
would improve conditions only
if the market generated enoughemployment. As population growth
rates often exceeded economic
growth rates, the gap would lead tounder- and unemployment, withsocial turmoil as a result.

CHAMPION OF CHANGE

Judith Bruce
As an observant adolescent, Judith Bruce
realized that unless aggressively challenged, theconventional process of “becoming a woman”
meant not only bodily changes but also a lossof freedoms. Young females’ choices about
sexuality and fertility were constrained not only
by insensitive health care but just as forcefully bya lack of an independent “voice” and income.
Even as her generation welcomed modern
contraceptives, Bruce questioned the heavy
reliance on technical fixes. In her early 20s,
she joined a class action case to support a
woman’s right to choice, and studied how
girls’ adolescence shaped their ability tolead dignified lives of their choosing.
Her intellectual path followed her lived
experience, as she published almost
simultaneously on women’s social and economic
bargaining power in households and on clientcentred care. Her “quality of care” framework
46

CHAPTER 3“Is it owing to overpopulationthat unemployment and poverty
exist in many countries of theworld today? No, absolutely not.
It is mainly due to aggression,plunder and exploitation by
the imperialists, particularly thesuperpowers,” said Huang Shu-tse,
head of the Chinese delegation in
Bucharest (Potts and others, 2018).
Karan Singh, the Indian Ministerof Health and Family Planning,argued that broader social andeconomic conditions were chiefly

underpinned a global shift in family planning
programmes from stressing numericaltargets as the success metric to promoting
sustainable and safe use by responding togirls’ and women’s priorities. This framework
contained six elements: ensuring that clients
have a choice of among a range of different
contraceptive methods appropriate to theirneeds; exchanging information with clientsto ensure informed choices; technicalcompetence of providers; respectful andsupportive interpersonal relations; followup and continuity mechanisms to address
discontinuation rates; and an appropriate
constellation of services to ensure that clients
receive the range of services they need toaddress both health needs and their widersocial setting.
This framework provided the foundation of theChinese State Family Planning Board-sponsored
Quality Project, which called for thereorientation of the national family planning
programme and was the institutional precursorof the discontinuation of the so-called one-childpolicy. Bruce was an architect of the 1994
International Conference on Population andresponsible for high fertility, andtherefore greater development
assistance, not family planningassistance, should be the priority.
“Development,” he said, “is thebest contraceptive” (Potts, 1992).
These conversations contributed
to an overall sense of ambivalence
about the efficacy of nascent familyplanning programmes and therelationship between population
growth and economic growth more
broadly. Indeed, numerous voices
raised questions about factors that

contribute to fertility decline andhasten the demographic transition indeveloping countries.
In Bucharest in 1974, John
D. Rockefeller III expressed“disappointment at the results ofthe family planning approach,” andurged reappraisal that would movebeyond the simple provision offamily planning. “In my opinion, if
we are to make genuine progress ineconomic and social development, if
we are to make progress in achieving
population goals, women increasingly

Development’s recognition that client-centred
reproductive health services and female empowerment
strategies were coequal, not competing, goals.
Today she calls for using the Sustainable
Development Goals to drive investment to hotspots
where child marriage, sexual coercion, unmet need,resource scarcity and intergenerational poverty
overlap. “Girls at the highest risk of the worst
outcomes are most likely to become single mothers
and sole household supporters,” she says. These
girls then become even more marginalized because
their household responsibilities exclude them fromseizing opportunities for learning, employment
and participating in their communities. Meanwhile,
their male counterparts are able to benefit from new,technologically driven economies.
“Without aggressive investment in girls aged 10 to14, countries cannot count on reaping a demographic
dividend,” she says. Not making these investments,
she says, amounts to planned poverty. And she
predicts “increasing pressures on young females
to trade sexuality and fertility for survival in
the face of increasing climate emergencies,
conflict, displacement, scarcity and stress.”must have greater freedom of choicein determining their roles in society”(Rockefeller, 1978).

Pushback on narrowly
defined population
policies
As national population policies
continued to expand through the
1980s, fear and mistrust of thosepromoting demographic goals
continued to mount. A growinginternational women’s healthmovement began to advocate for

Bruce calls for reversing this planned poverty andthe poor reproductive health that accompanies it byimplementing age-, gender-, and place-specific plans
for those most likely to be left behind. The starting
point for change: the 50 million 10-year-old girls in
the poorest countries today.
© Nadia Todres

programmes that ensured not justaccess to family planning, but amore holistic approach to women’s
reproductive health, including
attention to issues of sexuality andgender relations.
While diverse in many ways, afundamental message united thewomen’s health movement: thedesign, implementation and evaluation of women’s health programmes
should be shaped by a concern
for reproductive health and rights,
and not by demographic objectives.
Women’s groups from around theworld increasingly called for policies
and programmes that treated womenas subjects, with their own needs andrights, and not merely as objects toachieve broader societal goals.
A growing number of voices
began calling for new research anddata about women’s needs andpreferences related to fertility andfamily planning, and many argued
that these needs and preferences,rather than demographic targets,should serve as the primary guideto population policies and familyplanning programmes. Indeed,
influential research carried out bySinding and others (1994) showedthat in the majority of countries
analysed, existing demand for familyplanning exceeded national targets forcontraceptive prevalence rates set bygovernments; therefore, they argued,
population policies with demographic
targets should be replaced with
objectives expressed in terms of thestated desires of the people served.

48

CHAPTER 3

Pitching a big tent: thelead-up to the ICPD
Individual and collective goals canbe reconciled within the broadumbrella of population policy: thismessage became the global rallying
cry in the preparations for the
ICPD, to be held in Cairo in 1994.
As a central organizing institution
along with the United Nations
Population Division, UNFPA
sought to build bridges withina movement that had become
increasingly divided. The institutions
sought to build on the earlyfoundations of the global population
movement, acknowledging thatan understanding of population
trends is critical to achieving
lasting development outcomes,
while simultaneously embracing an
understanding of the central role ofwomen’s lives—and promoting theirrights and choices as a basic tenet of
population policy.
Under the leadership of UNFPA
Executive Director Dr. Nafis Sadik,
the ICPD Secretariat guided a
process that resulted in a consensusdriven Programme of Action thatradically transformed views on
how population policies should
be developed and implemented inxthe future.
The road to Cairo was long anddeliberate. The first preparatory
meeting was held in 1991, where,
for the first time, “development”
became part of the title of aninternational conference on
population, and a draft programmeof action was reviewed, debated andaccepted by States in subsequent“preparatory committee” meetings.
Alongside the preparatory
meetings, the ICPD Secretariat
organized expert group meetings totackle thorny issues like population
growth, migration, family planningand health, and population andenvironment. It organized five
regional meetings to ensure broad
geographic input and buy-in and,critically, organized numerous
formal and informal gatherings of
non-governmental organizations,enabling diverse and robust
participation from a wide spectrumof interest areas.
The numerous consultations,multiple meetings, and strategic
advocacy and engagement of
stakeholders paid off. In the final
Programme of Action, governments
agreed, for the first time, that
population policies should include a
broad swath of social development
considerations. They arrived at aconsensus that family planningshould be delivered in the context
of comprehensive reproductive
health care, incorporating efforts
to ensure healthy and safe
childbearing, prevent sexuallytransmitted infections, and address
related reproductive and sexual
health concerns, including genderbased violence and other harmful
practices. Women’s empowerment
and gender equality were lifted up as
fundamental elements of populationand development policy.

CHAMPION OF CHANGE
Born in 1929, Nafis Sadik grew up in a tumultuous timein history, one that in 1947 saw the birth of her country,
Pakistan. It was not a particularly favourable moment tobe a girl. But Sadik had a vision that she could change theworld for the better. And this she did, by galvanizing people to come together around a wholly new
understanding of population and development in 1994.

Nafis Sadik

She challenged convention from the start. She completed a medical degree in obstetrics, served
poor rural women and men, and helped shape the first national population policy for Pakistan.
When she joined UNFPA and rose through its ranks to become its second Executive Director in
1987, it marked the first time that a woman headed one of the major voluntarily funded United
Nations programmes. She quickly became a passionate advocate for giving women the tools, frominformation to contraception, to manage their reproductive lives. Travelling the world, she heard
women’s stories and made them into a relentless crusade for their rights to be healthy and live
free from violence.
In the early 1990s, the Secretary-General of the United Nations chose Sadik to lead preparations
for the International Conference on Population and Development. It became the largest gathering ofgovernments on the subject in history, and revolutionized the approach to sexual and reproductive
health and rights. Under Sadik’s
persuasive influence, civil society
groups took prominent roles at allstages of the process, setting a newnorm for activist engagement ininternational political talks.

“People areat the heartof the process,as agents andbeneficiaries.”

As the conference began, Sadik stood
before delegates and said with typicalforthrightness, “Any form of coercion
in population policies and programmes
is unacceptable. Women and men havethe right to choose the size and spacingof their families, and to the informationand the means to do so.”“People are at the heart of the process,as agents and beneficiaries,” shedeclared. “We have it in our power tolighten their burdens, remove obstaclesin their path and permit them thefull flowering of their potential as
human beings.”© ZUMA Press, Inc./Alamy Stock Photo

STAT E OF WOR L D POPUL AT I ON 2 01 949

© Mark Tuschman

Underlying this emphasis was ashared understanding that enhancing individual health and rights
would contribute to lower fertility
and slower population growth. By
placing the causes and effects of
rapid population growth in thecontext of human development andsocial progress, governments andcivil society from multiple political,
cultural and scholarly viewpoints
could join in support of the recommendations (Ashford, 2001).
Unlike outcome documents fromprevious international population
conferences, the Programme of50

CHAPTER 3

Action contained an openness
and sensitivity in its treatmentof issues related to sexuality,
reproduction and gender relations.
It emphasized the crucial links
between sexual and reproductive
health and rights with almost
every other aspect of populationand development: urbanization,
migration, ageing, changing family
structures and the rights of young
people. By way of comparison,
neither the World Population
Plan of Action resulting from the1974 Bucharest conference nor therecommendations from the 1984

Mexico City conference included
the terms “sexual” or “sexuality”(United Nations, 1995).

Taking the lessons
forward
The results of the consensus
achieved at the ICPD were
profound and enduring. Gone
were the top-down, demographic
targets of the past; today’s notionsof “population policy” reflect thebroad consensus that women’s
education, empowerment andequality are paramount. The
importance of providing family

planning in the context of fullsexual and reproductive health careis fully embraced.
That said, many continue todraw attention to the ways in which
demographic trends may hinder
the achievement of development
outcomes. For example, rates of
population growth remain highin many areas that are steeped inpoverty and conflict, or vulnerable
to climate change or natural
disaster. At the other end of thespectrum, persistent low fertility
and population ageing have raised
concerns about economic healthand society’s ability to provide
adequate social safety nets.
Undeniably, population dynamics
shape and are shaped by societal
conditions. The relationships
are complex, multivariate andmultidirectional. The lessons of thepast have shown that top-down,
State-sponsored efforts to engineer
or alter demographic trends are afool’s errand: they are instruments
too blunt to achieve intended
outcomes, they place undue
limitations on individual choice,and they risk egregious violationof human rights.

But greater understanding ofdemographic trends and theirrelationship to development
objectives is needed. Theinternational community has
a responsibility to gather andcommunicate data that shed lighton those relationships, while
continuing to highlight the primacyof rights and choices in all aspectsof life, but particularly in accessing
sexual and reproductive healthinformation and services.

CHAPTER HIGHLIGHTS•

In the 1970s, governments, non-governmentalorganizations and development institutions
supplied an increasing quantity of reliable,
modern contraceptives to empower women
to manage their own fertility.

By 1994, when the International Conference on
Population and Development (ICPD) took place,a global consensus had emerged that women havea right to make their own decisions about whether,when and how often to become pregnant. The
Programme of Action from the ICPD showed that
reproductive rights and sustainable development
are mutually reinforcing.

•Achieving demographic targets was the main
goal of some early family planning programmes,
sometimes compromising the quality of
reproductive health services.

The achievement of rights and choices for all will
depend on a continued partnership among civilsociety, governments, academia and international
institutions.

•

The success of the United Nations Sustainable
Development Goals depends in part on achieving
universal access to sexual and reproductive health.

•

The United Nations established UNFPA in 1969,
at a time of rapid population growth, to help
countries analyse demographic trends and theirrelationship to economic and social development.

••

STAT E OF WOR L D POPUL AT I ON 2 01 951

© James Blair/National Geographic Image Collection

CHAPTER 4

AVAILABLE
BUT INACCESSIBLE
The growth of national population programmes and donor
funding for them exponentially increased the availabilityof contraceptives in developing countries in the 1970s
and beyond.

The International Planned
Parenthood Federation, too, wasgiving voice to women aroundthe world who were demanding
information and services that would
enable them to exercise control of
their fertility. Top among the goalsof the Federation was expanding
options for preventing pregnancy.
In the 1950s, the most common
contraceptive methods were largely
controlled by men: the malecondom, withdrawal and periodic
abstinence. Margaret Sanger,
one of the founders of Planned
Parenthood, was particularlyinterested in developing a pill,

as easy to take as aspirin, thatwould enable women to prevent
pregnancy. In 1953, she introduced
American feminist philanthropist
Katharine Dexter McCormick to
Dr. Gregory Pincus. McCormick
provided financing for Pincus’
research into a hormonal oral
contraceptive, and by 1960, “thepill” was on the market.
In 1970, the Population Council
established the International
Committee for Contraception
Research to further expand
availability of contraceptive options,
including long-acting ones, such as
implants and injectables.

By 1976, more than 100
governments were providing
contraceptive information andservices, either directly throughgovernment clinics or throughnon-governmental organizations.
The number of countries making
modern contraception available
had grown to nearly 140 by 1986
and to 160 by 1996 (United
Nations, 2013). By 2015, only
6 per cent of governments provided
no support for family planning:these governments, however,allowed the private sector toprovide family planning services
without giving them any material

STAT E OF WOR L D POPUL AT I ON 2 01 9

53

or financial support (United
Nations, 2017a).
As government support forfamily planning and the numberof methods grew, so too did
the number of people availingthemselves of contraception.
Worldwide, the proportion of
married or in-union women who
reported using a contraceptive
almost doubled between 1970 and2015, from 36 per cent to 64 percent (United Nations, 2015).
Over the past half century,
governments and the international
donor community expanded theavailability of multiple methods
to people everywhere, leading
to a broad method mix that isevident today.

More than familyplanning
As efforts to expand familyplanning programmes rolled out
across the globe, women’s issues
were moving to centre stage. In
1975, for example, the United
Nations declared the openingof the Decade for Women, andmultiple international conferences
and regional gatherings enabled
women across the world to meet,share information and advocate forchange. More and more women
were demanding agency in theirreproductive lives, and suchagency, they asserted, extended
beyond the simple availability offamily planning. For example, in
response to sobering new evidence

54

CHAPTER 4

of hundreds of thousands ofwomen dying during pregnancy orchildbirth every year, the women’s
health movement fuelled the launchof the global Safe Motherhood
Initiative in 1987. The Initiative
aimed to reduce maternal mortality
by 50 per cent by 2000 throughstrengthening community-based
health care and developing alarmand transport systems to enableat-risk pregnant women to reachlife-saving maternal health services.
Meanwhile, civil society
organizations were calling for
replacing narrowly focusedfamily planning programmesthat prioritized dispensing
contraceptives with broader
reproductive health care. They
argued that the availability offamily planning was only one partof the picture—that to ensure
rights and choices in people’s lives,
all people needed and deserved acomprehensive suite of informationand services related to sexuality andreproductive health.

So close yet so far
In 1994, the Programme of Action
resulting from the International
Conference on Population
and Development not only
acknowledged that family planningand sexual and reproductive healthand reproductive rights wereintertwined, but also called on
States to provide access to: antenatalcare; safe delivery and postnatalcare; treatment of infertility;

safe abortion where legal, andmanagement of the consequencesof unsafe abortion; treatment ofreproductive tract infections andsexually transmitted infections;and information, educationand counselling on sexuality,
reproductive health and responsible
parenthood.
The Programme of Action alsoaffirmed that referral for these
services, and for breast cancer andcancers of the reproductive system,
should always be available; andthat discouragement of harmful
practices, such as female genital
mutilation, should be an integral
component of primary health care
(United Nations, 2014a).
The term “access” underscoredthe point that making reproductive
health services available wasinsufficient to enable everyone toenjoy their reproductive rights.
Rights are universal, which meansthat everyone has them. A woman
who, for example, is unable to avail
herself of family planning services,even when they are available, isdenied her right to plan her family.
Social, economic and other barriers
to access would therefore haveto be removed for rights to be
fulfilled.
One of the simplest and mostbasic definitions of “access” isgeographic proximity to servicedelivery points. Great distances
can hamper access, either because
affordable transportation options
are limited or because the© Patrick Zachmann/Magnum Photos

opportunity costs for poor womenleaving their homes or livelihoods
are too high. But distance is only
part of the challenge. Sometimes
services are available literally
around the corner, but they arestill inaccessible.
A nearby family planning clinic,
for example, may offer services, but
a judgemental service provider may
refuse to dispense contraceptives
to a young person or an unmarried
woman. That same clinic may
also offer only one or two modern
methods of contraception, but

not the method preferred by some
women. Supplies of contraceptives
may be unreliable. There may belaws that block access to services bycertain groups, or husbands may
forbid their wives from using any
form of contraception.
Over time, researchers andpractitioners have helped to
articulate concepts of access thatare multidimensional, recognizingthat access is affected by factors
at the levels of the individual,
community, provider and servicedelivery points. Enhanced

concepts of access acknowledge
the many barriers to individuals’
abilities to avail themselves of
information and services thatenable health, well-being and therealization of rights and choices intheir sexual and reproductive lives.

Overcoming barriers
to accessIn the past half century, great
progress has been made in extending
access to sexual and reproductive
health services and information topeople everywhere. But this progress

STAT E OF WOR L D POPUL AT I ON 2 01 955

has been uneven and inequalities
persist, both within and between
countries—not only for traditional
concerns around family planningand maternal health, but for
information and services that canenable the realization of the fullrange of sexual and reproductive
health and rights.
Multiple social, institutional,
political, geographic and economic
forces are at play. Sexual andreproductive health inequalities are
deeply affected by income inequality,
the quality and reach of healthsystems, laws and policies, socialand cultural norms, and people’s
exposure to sexuality education.
Income inequality

Within most developing countries
today, access to critical sexualand reproductive health careis generally lowest among thepoorest 20 per cent of households
and highest among the richest
20 per cent (UNFPA, 2017). The
relationship between poverty andlack of access is complex: while
financial costs of health services
and supplies can be a barrier
to access in some cases, income
is linked to numerous social,
institutional, political, geographic
and economic forces that can also
affect an individual’s access.
Women in the poorest
households may find themselveswith little or no access to sexualand reproductive health care,leading to unintended pregnancies,
higher risk of illness or death frompregnancy or childbirth, and theneed to give birth on their own,
without the assistance of a doctor,
nurse or midwife.

For these women, their poor
sexual and reproductive healthcan block opportunities, blunt
their potential, and solidify theirposition at the bottom rung of
the economic ladder. Indicators
paint a picture of vast differencesamong wealth quintiles for many
critical sexual and reproductive
health services (UNFPA, 2017).
For example, in the majority
of developing countries, theproportion of the demand forfamily planning that is met
through modern contraception,
the access to adequate antenatalcare, and the likelihood ofgiving birth with assistance isdramatically lower among thepoor than it is among wealthierhouseholds (Figures 4.1, 4.2, 4.3).
Over the past 50 years, great
strides have been made in© Giacomo Pirozzi/Panos Pictures

FIGURE 4.1
Percentage of family planning demand satisfied

Proportion ofdemand forfamily planning
met with modern
contraception,
by developmentlevel, place ofresidence andwealth quintile,
latest year
available

Least developed (33 countries)
100
90
80
70

64

59

60
39

40

51

46

41

38

34

66

64

61

59

55

50

50

30
20
10
0

URBAN

RURAL

BOTTOMSECOND

THIRD

FOURTHTOP

WEALTH QUINTILE

Less developed (41 countries)

Least developed (35 countries)

FIGURE 4.2

More developed (10 countries)

100
90
Percentage of women receiving
four or more antenatal visits

Proportion of
women having
four or moreantenatal visits,
by developmentlevel and wealthquintile, latest
year available

Less developed (41 countries)

80
70

89

85

82

78

75

72

86

81
67

63

60
50

54

47

41

37

40

90

30
20
10
0

BOTTOMSECOND

THIRD

FOURTHTOP

WEALTH QUINTILE

FIGURE 4.3
Percentage of childbirths with skilled attendant

Proportion ofbirths with skilledattendants, bydevelopmentlevel, place ofresidence andwealth quintile,
latest year
available

Least developed (35 countries)

100
90
80

94

Less developed (46 countries)

99

99

81

More developed (10 countries)

100

99

98

88

82

79
70

70
60

100

97 99
86

69
55

48

50

93

45
36

40
30
20
10
0

URBAN

RURAL

BOTTOMSECOND

THIRD

FOURTHTOP

WEALTH QUINTILESTAT E OF WOR L D POPUL AT I ON 2 01 9

57

reaching new populations withsexual and reproductive healthinformation and services. Figure
4.4 shows that in many countries,
remarkable progress has been madein expanding access to services
that have dramatically decreasedmaternal mortality: globally,
the maternal mortality ratio has
experienced a decline of nearly
44 per cent, with progress seenin every region (Alkema andothers, 2016).
But in many other places, thepoorest populations have not yet
shared equally in this progress. The
vast majority of maternal deaths,
for instance, occur in low-resource
settings, and poor women withlimited access to prenatal care, skilled
birth attendance, and emergency
obstetric care are more likely tosuffer debilitating health impacts
and pregnancy-related injury, suchas obstetric fistula. Greater effort isneeded to advance information andservices designed to prioritize thepoor and hard to reach.
Examples of such efforts offerhope. In Bangladesh, Bhutan,
Cambodia and Thailand, forexample, contraceptive prevalence
rates are higher among the poorest
20 per cent of the population thanthey are among the richest 20 per
cent. In these and several othercountries, concerted efforts to
expand family planning coverageto the hardest to reach have led tonear-universal access to modern
contraception, and near-equitable

58

CHAPTER 4

Contraceptive
prevalence rates
are generally lower
among the poorest 20%of the population
20

40

60

80

and highest among
the richest 20%
UNFPA, 2017

rates of contraceptive prevalence
among rich and poor households
alike (UNFPA, 2017).
Innovative service-delivery
models have helped expand
access to the poorest populations.
Community-based distribution
systems initiated in the 1970s, forexample, helped to extend accessto poor and rural communities
through trained members of thecommunity. While traditionallythese efforts were focused on
expanding access to contraceptives
such as pills and condoms, efforts
have been made to expand theservice mix to include emergency
contraception, birthing kits andmisoprostol for the preventionof post-partum haemorrhage(Bongaarts and others, 2012).
More recently, demand-side
financing strategies, such asvouchers, have been introduced
as a way of giving more decisionmaking ability to poor clients. In
this model, clients can purchasevouchers for specific reproductive
products at a subsidized price.
The vouchers can be exchanged
for services—including services
as diverse as information about
long-term family planning, andinformation and services for safedelivery and gender-based violencerecovery—at qualified outlets(Bongaarts and others, 2012).
Conditional cash transfers have also
been introduced as a strategy toincentivize actions and behaviours
that contribute to critical healthoutcomes, such as antenatal healthvisits, keeping girls in school, ordelaying marriage (Bongaarts andothers, 2012).
Insufficient facilities, providers
and supplies

A woman who seeks sexual andreproductive health information andservices may find no provider in her
community. If she has the means tocover the cost of transportation to aclinic in a neighbouring community,
she may arrive only to find thatit lacks the proper equipment or
supplies for the services she needs.
There may be no health service
provider, or not enough providers,
to see everyone who has turned
up that day. If there are enoughproviders, they may not havethe training to offer appropriate
information or services, or perhaps

FIGURE 4.4

Northern Africa
Caucasus andcentral Asia
Developed regions

200

Global and regional
estimates of maternalmortality ratio,
1990–2015

150

Sub-Saharan Africa

1000

500

100

50

Maternal deaths per 100,000 live
births. Shaded areas are 80 per centuncertainty intervals. Shaded areas
in background are comparable.

0

0
1990

1995

2000

2005

2010

2015

1990

1995

Year

Caribbean
Latin America

350
300

500

250

400

200

2005

2010

2015

Year

Southern Asia
Southeastern Asia
Western Asia
Eastern Asia

600

2000

Oceania

700
600
500
400

300

150

300
200

100

200
100

50
0

0

1990

1990

1995

2000

2005

2010

2015

100
0
1995

2000

2005

2010

Year

Year

2015

1990

1995

2000

2005

2010

2015

Year

Worldwide
400

300

200

100

Worldwide, there has been remarkableprogress in addressing maternal mortality,with a decline of nearly 44 per cent in
the maternal mortality ratio since 1990. Suchprogress, however, differs greatly between regions.

0
1990

1995

2000

2005

2010

2015

Year

Source: Alkema and others, 2016

STAT E OF WOR L D POPUL AT I ON 2 01 9

59

The importance of quality
Quality is a critical dimension of access to services.

for ensuring those rights are the individuals who are

Judith Bruce’s seminal work in defining a framework

in direct contact with clients: the providers. Therefore,

for quality of care outlined six elements that deserve

strategies for quality of care must also recognize that

attention from the perspective of a family planning

service providers have their own needs, and should beclient: choice of methods; information given to clients;

able to expect training, supplies, guidance, back-up,

technical competence; interpersonal relations; follow-

respect, encouragement, feedback and self-expression

up and continuity mechanisms; and the appropriate(Huezo and Diaz, 1993).

constellation of services (Bruce, 1990).
The relationship between clients’ rights and providers’
Recognizing that too many women were not benefitingneeds is central to any effort to remove obstacles tofrom actions to improve reproductive health, international

quality of care. Promising interventions include thoseinstitutions and nine countries launched the Networkthat facilitate a better interaction between clients andfor Improving Quality of Care for Maternal, Newborn

providers through means such as training providers

and Child Health, or the “Quality of Carein interpersonal communication. Resulting

Network,” in 2017. Network members agreed

improvements in these dimensions of quality

on a vision that every pregnant woman andof care are possible without the need for“too little,
newborn receives high-quality care throughout
pregnancy, childbirth and the postnatal period,
too late”
a vision that is underpinned by the core values
orof quality, equity and dignity (WHO, 2018).
“too much,
The element of quality in all dimensions of sexual
too soon”
and reproductive health is supported by thebroad health-care framework known as AAAQ,
for availability, access, acceptability and quality,

large investments in staff, equipment or
supplies (RamaRao and Mohanam, 2003).
Limitations on quality of care can havesignificant implications for maternal health.
While more and more women are giving
birth in health facilities rather than athome, a lack of adequate staffing, training,
infrastructure and commodities can result

which has been advanced as a key component of rights

in poor quality care, known as “too little, too late” orin health care by the United Nations Committee on

TLTL. The converse also poses challenges: in some

Economic, Social and Cultural Rights (UNCESCR, 2000).

regions the rapid increase in the use of facilities forchildbirth has been accompanied by widespread

In 1992, the International Planned Parenthood Federation

over-medicalization of birth, resulting in, for example,

had advanced a “bill of rights” for family planning clients

overused or unnecessary caesarean sections, orthat outlined what individuals seeking family planningcaesarean sections that are provided in unsafe or low-should be able to demand if they are receiving high-quality

quality conditions, resulting in injury to mother andcare from providers. These include rights to information,baby. This phenomenon, known as “too much, tooaccess to services and choice, as well as safety and thesoon” or TMTS, can have the effect of offsetting gains

right to privacy, confidentiality, maintenance of dignity,in maternal and perinatal health. For both TLTL andcomfort, continuity and expression of opinion.

TMTS, improved provider training in respectful care
and adherence to best practices can help to strengthen

While responsibilities for quality of care are, in principle,

maternal and perinatal outcomes, avoid harm, anddistributed through the entirety of a family planning

reduce health-care costs and inequities (Miller andprogramme, those who are seen as most responsible

others, 2016).

60

CHAPTER 4

may not be able to offer privacy orother measures that would enable
her to feel safe and respected.
Research, anecdotal information
and reports by civil society havelong confirmed the shortcomings ofservices. A recent review of healthfacilities in 10 African countries,
for example, found overall low
levels of readiness when assessing
the availability of key supplies andservices, including family planningguidelines, staff trained in familyplanning, blood pressure apparatus,
combined oral contraceptives,
injectable contraceptives and male

© B. Sokol/Panos Pictures

condoms (Ali and others, 2018).
More systematic attempts
to quantify and monitor
overall readiness remain underdevelopment. The World HealthOrganization, in partnership withother organizations, regularly
releases guidance notes on standardsof good practice for a variety of
reproductive health interventions.
A 2017 assessment of 24
countries indicated that familyplanning services run out of stockof some methods of contraception
about three quarters of the time. An
average of 78 per cent of primary-level facilities offering three or moremethods of contraception had themin stock on the day of assessment;
79 per cent of secondary andtertiary facilities (regional andlarger hospitals) offering five or
more methods had them in stock(FP2020, 2018). These averages,
however, mask wide variations
within and between countries.
“Reproductive health commodity
security” is achieved when all
individuals can have access toaffordable, quality supplies,
including the contraceptive methodof their choice, whenever they© UNFPA/M. Bradleyneed them. Towards this goal,a partnership with the Bill &Melinda Gates Foundation andthe United Kingdom Department
for International Development
is expediting the delivery of
reproductive health commodities
to countries to avoid stock-outs(UNFPA, 2018).
In many places, the numberof trained providers is simply
insufficient to ensure adequate
access to a full range of sexual andreproductive health informationand services. The Global Health
Workforce Alliance has cited a needfor increasing the number of healthworkers, particularly skilled birthattendants, in developing countries(Campbell and others, 2013). Over
all categories of health workers,
there was an estimated global
shortage of 7.2 million healthworkers earlier this decade.

62

CHAPTER 4

The need for trained professionals
who can deliver essential sexualand reproductive health services isparticularly acute. A recent analysisof 73 low- and middle-income
countries found that while morethan 92 per cent of the world’s
maternal and newborn deaths
and stillbirths occur within thosecountries, they are home to only
42 per cent of the world’s medical,
midwifery and nursing personnel(UNFPA, 2014).
Estimates of outlays for
personnel needed to achieve
universal coverage levels for key
reproductive, maternal, neonatal
and child interventions suggest that
substantial increases will be needed.
To attain levels to meet all unmet
need for reproductive, maternal
and newborn health worldwide, forexample, an estimated 37 per centincrease in funding for personnel

to dispense contraception would
be required; maternal and newborn
health would require increases ofabout 20 per cent above current
levels (Guttmacher Institute,2017).
These global averages hidesignificant regional disparities. In
the least developed countries, forexample, outlays for personnel
to address unmet need forcontraception alone would need
to be 96 per cent higher, and forfull maternal and neonatal services
coverage, 84 per cent higher. The
payoff for such investment would behigh: estimates suggest that maternalmortality and recourse to abortion
would be reduced by as much as
three quarters with full staffing,equipment and system maintenance(Guttmacher Institute, 2017).
The preparedness of providers
to offer adequate care has beenlong appreciated regarding familyplanning. Insufficient counselling(that which fails to addressquestions about proper use; to offer
advisories about contraindications,side effects and appropriate followup, including method switching;or to help in addressing the context
of use, including partner concerns)
can be an obstacle to contraceptive
access, adoption and continuation.
Findings from studies ofreasons for unmet need for familyplanning suggest that the provisionof a range of methods andinformation and counselling tohelp women select and effectively

Legal barriers

use an appropriate method can be
critical in overcoming obstacles
to contraceptive use. The mostcommonly reported reasons for
non-use include infrequent sex
and concerns about side effects
or health risks (Sedgh andHussain, 2014).
Contraception discontinuation
is an often ill-addressed dimensionof unmet need. A recent analysisof 32 countries indicates that, on
average, more than one fifth of
episodes of short-term methods(condoms and pills) are stopped
within 12 months, despite the user
still wanting to prevent pregnancy(FP2020, 2018). Discontinuation
rates within one year are lower for
long-acting methods: 12 per centwith intrauterine devices and8 per cent with implants.

FIGURE 4.5

Even in places where there
are well-trained providers andfacilities are well-stocked andequipped, individuals may facelegal barriers that limit their accessto information and services. In
some places, laws require thirdparty authorization for womenor adolescents to access healthservices. Elsewhere, laws thatcriminalize same-sex relationships,
sex work and drug use can force
people into hiding and prevent
them from seeking or receiving theinformation and services they need.
While intended to protect
minors, age-of-consent laws for
medical services can discourageadolescents from accessing
needed services related totheir sexual and reproductive

health. This can be particularly
harmful for adolescent girls,
who bear disproportionate socialand physical consequences ofunintended pregnancies.
In 2017, 68 of 108 countries
reporting data to the Joint United
Nations Programme on HIV/AIDS(UNAIDS) indicated that theyrequire parental consent for a childunder 18 years to access sexual andreproductive health services (Figure
4.5; UNAIDS, 2018). In somesettings, health-care providers arelegally required to report underagesex or other illegal activities among
adolescents (Delany-Moretlwe andothers, 2015).
Legislation that bans intercourse
between consenting adults of thesame sex can interfere with efforts
to provide access to services to

Discouraging adolescents from accessing services

Countries with age of consent laws to access sexual and reproductive health services, 2018
Countries with age of consent laws to access sexual and reproductive health services, 2018
Reporting countries
Countries with laws requiring parental consent for adolescentsto access sexual and reproductive health services

52%

53%

92%

59%

90%

58%

61%

57%

Asia andthe PacificEastern andsouthern Africa

Eastern Europe
and central Asia

Latin America

Caribbean

Middle Eastand North Africa

Western andcentral Africa

Western andcentral Europe
and North America

Source: UNAIDS, 2018

Source: 2017 and 2018 National Commitments and Policy Instrument.

STAT E OF WOR L D POPUL AT I ON 2 01 9

63© Giacomo Pirozzi/Panos Pictures

prevent or treat sexually transmitted
infections, including HIV. As of
2017, more than 40 countries
reporting to UNAIDS stated they
have laws specifically criminalizing
same-sex sexual intercourse. Amongthese, two apply the death penalty,
and some others may imprison
people for life (UNAIDS, 2018).
As a consequence, many people
fear seeking critical services such as
HIV testing.
Laws regarding access to abortion
fall along a continuum, from totalprohibition to no restrictions. Asof 2017, 42 per cent of womenof reproductive age live in the
125 countries where access tosafe abortion is highly restricted.
Of all abortions worldwide, only
55 per cent are safe, relying on
a recommended method andadministered by a trained provider(Singh and others, 2018).
Evidence suggests that thefrequency of abortion is not

64

CHAPTER 4

significantly impacted by legal
restrictions: abortion rates incountries with the most restrictive
abortion laws are roughly the sameas abortion rates in countries withthe least restrictive abortion laws.
However, the more restrictive
the legal setting, the higher the
proportion of abortions that areunsafe—ranging from less than
1 per cent in the least restrictive
countries to 31 per cent in the mostrestrictive countries (Singh andothers, 2018).
In developing regions combined,
except East Asia, an estimated
6.9 million women are treatedannually for complications related
to abortion. Many more requirepost-abortion care but are unable toaccess it (Singh and others, 2018).
Norms, attitudes and practices

Across societies worldwide,
expectations dictate that sexual
activity and reproduction shouldtake place only among groups
with certain characteristics; thosecharacteristics often include
individuals who are heterosexual,
married, monogamous, ablebodied, not too young, and not too
old. In many places, childbearing
practices are expected to adhere notto the interests of the individual,
but to prevailing norms in families
and communities.
Such expectations may result
from long-standing attitudes andpractices, or prevailing religious
beliefs. When a person’s sexual andreproductive activities fall outsidethese expectations, it is likely that
it will be more difficult for that
person to access information andservices to meet their needs.
Adolescents face particularchallenges. Despite widespread
evidence that many unmarriedadolescents are sexually active(Starrs and others, 2018), social
norms may preclude or outrightprohibit discussions of sexualand reproductive health orsexuality. In addition to legal
barriers, challenges to access may
come in the form of insufficientsexuality education in schools, orin providers’ attitudes and beliefs
about the appropriateness ofinterventions in the context ofage or marital status.
Ethnic minorities, indigenous
people, sex workers, people withdisabilities, the poorest womenand girls, and the lesbian, gay,bisexual, transgender and intersex

CHAMPION OF CHANGE

Mechai Viravaidya

Mechai Viravaidya has galvanized
a no-holds-barred revolution in
Thailand, one fired by the belief thateveryone should know how to plan
their family and protect their health.

A communications mastermind, Mechai has since the 1960s reached people with messages about
condom use through schools and gas stations, in offices and villages, through pig-breeding contests
and visits by Avon ladies and ceremonies by Buddhist monks. It was all part of a drive to makecontraception an accepted, non-embarrassing feature of everyday life.
“Say the word ‘condom.’ Make it available. Talk about it,” Mechai says. “In fact, what we’re teachingis … the right for you to choose the number of children you want.”
While condoms offered a tactile and at times humorous entry point for education, Mechai’s aim wasalways having a wide variety of contraceptives found as easily as “vegetables in the villages.” Withina few decades, Thailand had moved a long way towards these goals, and the size of the average Thaifamily plummeted from 7 children to 1.6.
In the early 1990s, when HIV prevalence was predicted to spike, Mechai persuaded theGovernment to boost the budget for prevention 50-fold and enlist people from all parts of public
service, business and communities to speak out about protection and condom use. Thailand
subsequently warded off an estimated 3 million HIV infections, and Viravaidya became known
as the “Condom King.” Today, “mechai” is slang for condoms.
Viravaidya still leads the largest Thai non-governmental organization,
the Population and Community Development Association, which since
1973 has championed rural development and health. Its activities
include the Mechai Pattana schools, which embrace principles of
equity and fairness inbringing high-quality
education—including
comprehensive
sexuality education—to
otherwise marginalized
communities. Genderequality is integral tothe curriculum. “Women are very, very importantin the development process,” Mechai says, adding,with a typically memorable flourish, “When you
have two brilliant arms, why use only one?”“Say the word ‘condom.’
Make it available.
Talk about it.”© Bangkok Post

CHAMPION OF CHANGE
When Lebogang Motsumi
speaks to other young people
about HIV and AIDS, she does
so from her own experience. In
telling her story, she hopes to inspire other young women and girls to stay in school, stayhealthy and make positive choices.

Lebogang Motsumi

A typical bold Facebook post: “Good morning, my name is Lebogang Brenda Motsumi aka African
Queen. I am NOT HIV, I am LIVING with HIV. I am not the virus, the virus lives in me. I am notdefined by HIV, but I define HIV.”
Almost a decade has passed since Motsumi learned she was HIV-positive. She was only 17 when she
was infected by her boyfriend, a well-known singer who later died. Motsumi did not go for testing
until a later partner insisted on doing so. A few days after learning she was positive, she made asuicide attempt. A month after that, she found she was pregnant and started taking medication
to protect her child.
She also began a remarkable journey, on social media,
as an inspirational speaker, and as an HIV activist andcoach speaking especially to young people. “My HIV
infection helped me find my purpose in life. I realizedthat I can turn my mess into a message, and use mypain to empower other people.”
The African Union has honoured her as a youth hero,and she sits on youth advisory boards for both the Unionand UNFPA. She also rallies people as an ambassador for
Zazi, a campaign encouraging South African women andgirls to “know your strength.”“We will find the cure to HIV,” Motsumi declares. “While
we try to find a cure, the education and empowermentof people living with HIV is our cure. And prevention for
those who are HIV-negative.”“I am not defined by HIV,but I define HIV.”© OneTwo Photography

(LGBTI) community face
marginalization and stigma thatcan result in significant barriers
to sexual and reproductive healthand the realization of rights andchoices. Girls and young womenwith disabilities, for example, arefrequently denied the right to makedecisions for themselves about theirreproductive and sexual health,increasing their risk of sexual
violence, unplanned pregnancy
and sexually transmitted infections.
They may not be seen as needing
information about their sexual andreproductive health and rights,
and therefore have little knowledge
about them, leading to outcomesthat further limit their choices andexacerbate marginalization. In one
study in Ethiopia, for example,
just 35 per cent of young people
with disabilities used contraceptives
during their first sexual encounter,and 63 per cent had had an
unplanned pregnancy (UNFPA,
2018a).
Stigmatization can prevent
individuals from seeking services
they need and are entitled to.
Unmarried women, for example,
may be hesitant to seek sexualand reproductive health care,particularly services such as
contraception and safe abortion.
Levels of unmet need for modern
family planning are much higher
among single, sexually active

women than among married
women due to such stigma (Singhand others, 2018).
Stigma not only impacts
the choices and decisions ofindividuals in need of informationand services, but can also affectthe actions of providers. In places
where abortion is broadly legal,
for example, persistent stigma
about the procedure can affect thewillingness of providers to counsel
or offer abortions. A recent
review found that some providers
held negative attitudes towards
abortion in most countries inSouth-East Asia and sub-SaharanAfrica, for example, and providers
also reported being stigmatized

Access to services for young people with disabilities
Women Enabled International helped develop

contraceptive and sexual and reproductive

guidelines for governments, service providers and other

health services available and consider

stakeholders to meet the sexual and reproductive healthsubsidizing such services for low-income

needs of young people with disabilities. The guidelines

young people with disabilities.

include actions to ensure availability, accessibility,
acceptability and quality services, as well as services toprevent or address the impact of gender-based violence:• Develop awareness-raising campaigns andeducational materials for caregivers and family
members of young people with disabilities on• Establish disability-sensitive protocols and guidelines
for follow-up visits with health-care providers,sexuality, contraceptive use and the availabilityof services.

management of side effects of medication ortreatments, and referral guidelines for further
assistance when necessary.

• Ensure that contraceptive information, goods
and services are available to young women andmen with disabilities. Men and boys should also

• Create accessible informational materials tailored forreceive information to help them understand the

young people with different types of disabilities andrights of young women and adolescent girls toappropriate at different ages that address the types ofuse contraceptives.

STAT E OF WOR L D POPUL AT I ON 2 01 9

67

Sexual and reproductive health and the advent of universal health care
Sexual and reproductive health in general, and family

place reinforced the notion of a continuum of care thatplanning in particular, were for decades sidelined inincludes sex and reproduction—from prevention of

global arenas that took up issues of primary health care.

pregnancy, to pregnancy, birth, infancy, postnatal careand childhood—and critical water and sanitation factors.

In 1978, for example, government representatives
converged in Kazakhstan for the International

Under this Goal 3—to ensure healthy lives andConference on Primary Health Care. The event

promote well-being for all at all ages by 2030—

concluded with the Alma-Ata Declaration, which

Target 3.7 aims for universal access to sexual

identified primary health care as the key toand reproductive health care and services,

attainment of health for all around the globe. But

including family planning, informationsome governments said the goals outlined in theand education, and the integration

declaration were too broad and therefore unattainable.

of reproductive health into national
strategies and programmes.

A year later, at a gathering of health and policy experts,
a consensus emerged on the need to focus on simple

Figure 4.6, which shows coverage ofbut high-impact primary health-care interventions

health interventions across the continuum

that promised to save lives in developing countries.

of care in the world’s poorest countries

These interventions, referred to as GOBI, for growthwith the greatest needs, reveals unevenmonitoring of children, oral rehydration, breastfeeding

progress in some sexual and reproductive

and immunizations, again failed to address fundamental

health areas. Coverage, while still suboptimal, is highest

sexual and reproductive health issues as part of primaryaround delivery and for schedulable immunizations

health care. But the global health community eventually(UNICEF and WHO, 2017). The times before pregnancy

recognized the importance of other essential primary

and after a recent birth, prime times for deciding oncare interventions, and agreed that family planning

future pregnancy intentions, remain underserved.

should be a priority (as well as female education andfood supplementation).

In October 2018, 40 years after the Alma-Ata
Declaration, delegates participating in the latest Global

The addition of family planning to the global primary

Conference on Primary Health Care finally acknowledged

health agenda foreshadowed the Millennium Development

the centrality of sexual and reproductive health in primary

Goals (MDGs), which included an objective to reduce

health care. The declaration from that gathering statedmaternal mortality worldwide by 75 per cent between

that primary health care “will provide a comprehensive

2000 and 2015. In 2005, five years into efforts to achieve

range of services and care, including but not limited to …

the MDGs, the United Nations agreed to add a target toservices that promote, maintain and improve maternal,

achieve universal access to reproductive health.

newborn, child and adolescent health, and mental healthand sexual and reproductive health.”

Health targets were scattered throughout four ofthe eight MDGs. But starting in 2015, with the new

The SDG target of universal health coverage includes

2030 Agenda for Sustainable Development and its

family planning as a core indicator along with antenatal

accompanying 17 Sustainable Development Goals

and delivery care and cervical cancer screening. In(SDGs), all health-related targets, including ones

recent years, sexual and reproductive health has been

related to sexual and reproductive health, were included

consistently included in indicators in global healthin one Goal. Having all health-related targets in one

policymaking.

68

CHAPTER 4

FIGURE 4.6

Major gaps in coverage

Median national coverage of interventions across the continuum of care among countries, with available datafrom 2012, from the Countdown to 2030 initiative, which tracks progress in the 81 countries that account for
more than 90 per cent of under-five child deaths and 95 per cent of maternal deaths in the world.
Country reporting data
Demand for family planningsatisfied with modern methods(among married or in-union women)aPRE-PREGNANCY

Antenatal care
(at least four visits)
Pregnant women livingwith HIV receiving
antiretroviral treatment

PREGNANCY

Neonatal tetanus protection

BIRTH

Skilled birth attendant
Postnatal care for mothers

POSTNATAL

Postnatal care for babies
Early initiation of breastfeedingb
Exclusive breastfeeding(< 6 months)bContinued breastfeeding (year 1)b
Diphtheria-tetanus-pertussis
immunization (three doses)

INFANCY

Measles immunization(first dose)
Rotavirus immunization
Vitamin A supplementation(two doses)
Careseeking for symptoms
of pneumonia

CHILDHOOD

Oral rehydration salts
treatment for diarrhoea
Population using basic
drinking-water services
ENVIRONMENT

Population using basic
sanitation services
0

25

50
Percentage

75

100

a	Refers to the prevention and planning of pregnancy and includes the time period prior to a first pregnancy and interpregnancy intervals as well as decision making on whether toever have a pregnancy.
b Infant and young child feeding indicators serve as a proxy for programme coverage for which measures are not available.
Note: Includes only interventions of relevance to all Countdown countries. Malaria-related indicators that Countdown tracks are not shown.
Source: Immunization rates, World Health Organization (WHO) and United Nations Children’s Fund (UNICEF); population using basic drinking-water services and sanitation services,
WHO and UNICEF Joint Monitoring Programme for Water Supply and Sanitation; antiretroviral treatment of pregnant women with HIV, UNICEF global database, July 2017, based on2017 estimates from the Joint United Nations Programme on HIV/AIDS; all other indicators, UNICEF global database, July 2017, based on Demographic and Health Surveys, Multiple
Indicator Cluster Surveys and other national surveys.

STAT E OF WOR L D POPUL AT I ON 2 01 9

69

© UNFPA

by their families, communities,
colleagues and policymakers forproviding abortions (Rehnström
Loi and others, 2015).
Insufficient education about
sexuality

Individuals’ lack of knowledge
can be a barrier to accessing
services. Misperceptions or a lackof understanding about sexuality,
the human body and development,rights and gender, and power in
relationships can stand in the wayof people’s rights and choices.

70

CHAPTER 4

Comprehensive sexuality
education is a curriculum-based
process of teaching and learning
about the cognitive, emotional,
physical and social aspects ofsexuality. It aims to equip children
and young people with knowledge,
skills, attitudes and values that will
empower them to: realize theirhealth, well-being and dignity;
develop respectful social and sexual
relationships; consider how theirchoices affect their own well-being
and that of others; and understandand ensure the protection of

their rights throughout their lives(UNESCO, 2018).
Initiating age-appropriatecomprehensive sexuality educationin primary school offers numerous
benefits, including helping
children to identify and report
inappropriate behaviour suchas child abuse, and supporting
the development of healthy
attitudes about their own bodyand relationships. Comprehensive
sexuality education should also
be available to those who are notenrolled in school.

Evidence confirms that sexuality
education does not hasten sexual
activity, but rather has a positive
impact on safer sexual behaviours
and can delay sexual debut. A
UNESCO review for the development of technical guidance oncomprehensive sexuality education
found that curriculum-based programmes contribute to delayed
initiation of sexual intercourse,
decreased frequency of sexualintercourse, decreased number ofsexual partners, reduced risk-taking,and increased use of condoms
and other forms of contraception(UNESCO, 2018). As with all

curricula, comprehensive sexuality
education must be delivered inaccordance with national laws andpolicies (UNFPA, 2016a).
About 80 per cent of 48
countries covered in a recent study
have policies or strategies that
support comprehensive sexuality
education (UNESCO, 2015).

Towards access for all
Ensuring access to informationand services is a priority for theinternational community. Overtime, policymakers, practitioners
and advocates have helped toanswer the important questions of“access to what?” and “access forwhom?” and “what does accessreally mean in practice?”
Today, there is a consensus
around the objective that everyone,
everywhere should have accessto high-quality information andservices for the full range of theirsexual and reproductive healthneeds over the course of theirlives. While remarkable progress
towards this objective is evident,
its full realization remains elusive
for many, due to lack of awareness,scant resources, insufficient
political will, or underlying
gender inequality.

CHAPTER HIGHLIGHTS•

To ensure rights and choices in people’s lives,
all people need and deserve a comprehensive suiteof information and services related to sexual andreproductive health.

•

While early programmes focused on expanding
the availability of contraceptives to womenaround the world, over time, the concept ofaccess has evolved. Advocates, practitioners
and policymakers helped to answer importantquestions of “access to what?” and “access forwhom?” and “what does access really mean inpractice?” As our understanding of barriers toaccess grows, and as new challenges emerge,
there is an ongoing need to raise these questions.

•

Enhanced concepts of access acknowledge themany barriers to individuals’ abilities to avail
themselves of information and services that enable
health, well-being, and the realization of rights andchoices in their sexual and reproductive lives.

•

While significant progress has been made inextending access to services and information thatenable the realization of the full range of sexual andreproductive health and rights, this progress has
been uneven, and inequalities persist. Sexual andreproductive health inequalities are deeply affectedby income inequality, the quality and reach of healthsystems, laws and policies, social and cultural norms,
and people’s exposure to sexuality education.

STAT E OF WOR L D POPUL AT I ON 2 01 971© Abbas/Magnum Photos for MFA Italy

CHAPTER 5

THE OBSTACLEUNDERLYINGALL OTHERS
The sexual revolution, fuelled in large part by the advent of reliable
and safe contraceptive methods, was well under way in wealthiercountries in the 1960s. At that same time, developing countries were
undergoing dramatic economic and social changes that fundamentallytransformed their societies.

These changes included shifts in
attitudes about what men andwomen could and should be doingin their lives.
At the same time, Ela Bhatt,
Sonia Montaño, Gloria Steinem andother feminists around the world
were raising awareness about genderinequality and its connection tosexuality, inequality in the family,
reproductive rights and sexual
violence. This broader vision ofgender inequality continues to playa central role in discussions around
reproductive rights today.

Of all the obstacles to theachievement and exercise of humanrights, including reproductive
rights, few have proven to be as
challenging to overcome as those
based on gender. Gender, theweb of expectations and norms
within a society that together
define what are appropriate maleand female behaviours, rolesand characteristics, is learned,
internalized and reinforced throughsocial interactions with others, thus
having a profound influence on
every domain of life.

While the expression of gendervaries across contexts, in virtually
all societies gender has been
defined in ways that subordinate
women (and those who are gender
non-conforming) to men, imbuing
definitions of masculinity andfemininity with different levels of
power and social authority. The net
result of these differences in mostsocieties has been a systematic
disempowerment of women andnon-gender-conforming groups,
who find their autonomy andability to freely make decisions

STAT E OF WOR L D POPUL AT I ON 2 01 973

FIGURE 5.1

The disproportionate burden of child marriage
on girls

Male

for themselves limited acrossalmost every aspect of life. Gendernorms wield a particularly large
influence in reproductive matters.

FemaleGender influences
and is influenced byreproductive rights

Bangladesh

Burkina Faso

Gender inequality limits theability of women to freely makefundamental decisions about when
and with whom to have sex, about
the use of contraception or healthcare, and about whether and when
to seek employment or whether
to seek higher education. Genderunequal norms and expectations
magnify the negative effects ofother impediments to rights andchoices. One example is with childmarriage, which is overwhelmingly
more common for girls thanboys (Figure 5.1). When a girl ismarried, she is less likely to go to,or complete, school or travel freely
outside of her home alone; more
likely to be subjected to genderbased violence; and less likely toknow about her body and rights.
Her limited mobility, schoolingand knowledge in turn reinforce
and perpetuate gender inequality.

Cameroon

Chad

Comoros

Dominican Republic

Ethiopia

GuineaHonduras

India

Madagascar

Malawi

Mali

0

20

40

60

80

Proportion of ever-married age 20–59
married before age 18

Source: MacQuarrie and Edmeades, 2015.

74

CHAPTER 5

100

Gaining the power
to choose
Overall, women today have more
control over their reproductive
lives than at any point in humanhistory, with profound implications
for individuals and societies. For
women in particular, being able

to choose how many children tohave, and when to have them,has opened the doors to lives not
dominated by childbearing andchild-rearing and has helped reduce
gender inequality.
As levels of reproductive choices
have expanded over time aroundthe world, women in mostparts of the world have started
having fewer children. This trend
towards fewer children has had
a number of benefits for womenin particular, including better
health for both themselves andtheir children, greater educational
attainment, increased participationin paid employment, andimprovements in how womenand girls themselves are viewed
and valued by society and within
their households (Stoebenau andothers, 2013). In many settings,
this has formed part of a virtuous
circle of empowerment, where
greater access to reliable ways ofcontrolling fertility has enabled
an expansion of rights in otherareas, which in turn has further
contributed to their ability to fully
exercise their reproductive rights.
The right of both womenand men to freely choose thenumber, timing and spacing ofchildren is now almost universallyacknowledged. Ultimately, almost
all of the 4.3 billion people ofreproductive age around the world
today will have had inadequate
access to sexual and reproductive
health services at some pointin their lives (Starrs and others,2018). And that access is heavily
dependent on prevailing gendernorms.

Power, voice and choice
In all societies, reproduction
is imbued with deep social
significance and cultural meaning,playing a critical role in marking
the transitions between thestages of life and in building
social status and identity. As
a result, behaviours associatedwith reproduction, including themanner in which families areformed and sexual behaviour,

are regulated through norms,
particularly those related togender. Such gender norms shapeand reinforce social, legal andeconomic systems.
Patriarchal societies are often
characterized by strong andpervasive sexual double standards(Heise and others, forthcoming),
where masculinity is definedin ways that reward sexual
prowess and where women are
rewarded for purity and chastity.
These gender-unequal norms
and attitudes are often used torationalize control over women’s
sexuality and reproduction.

A UN film-maker, editor-and mother-to-be checks her film at UN Headquarters.
The symbol for international Women’s Year can be seen in the background and on the
speaker to the right. New York, 1974. © UN Photo/M. Faust

STAT E OF WOR L D POPUL AT I ON 2 01 9

75

Concerns over maintaining
women’s sexual purity underpin arange of harmful practices, such as
child marriage and female genital
mutilation, and are often usedby men as a justification forgender-based violence.
The harmful practices that
result from unequal gender norms
can further impede access tosexual and reproductive healthservices and limit a woman’s rights
and choices in all areas of her life.
Gender-based violence: Violenceagainst women and girls is ahuman rights violation and publichealth concern across all countries.
One in three women worldwide
will experience physical or sexual
violence at some point in her
lifetime (García-Moreno andothers, 2013). The existence andeven threat of violence creates anenvironment where women are
subjugated by men in sexual andreproductive health matters andare at increased risk of sexuallytransmitted infections andunwanted pregnancies.
Child marriage: An estimated
800 million women alive today
were married when they werechildren. Child marriage denies
a girl agency and autonomy
in her home and in sexual andreproductive decisions, reduces
her chance of being educated,
undermines her future and blocks
her from realizing her full potential
in life. Married girls are less likely
than adult women to receive76

CHAPTER 5

adequate medical care during
pregnancy, and that lack of care,coupled with the fact that many
married girls are not yet physicallyready to give birth, presents risks
for both mothers and babies.
The lack of autonomy that childbrides have in terms of being able
to make reproductive decisions,combined with the restrictions onmobility that many child brides
have, restricts their ability to makereproductive choices freely andtheir ability to act on those choices
by visiting health providers.
Fertility pressure and son
preference: Because reproduction
is seen as a fundamental part ofsocial ideals of both masculinity
and femininity, both men andwomen can face considerablepressure to prove their fertility
early in marital relationships.
A similar pattern is also seenin contexts where there is astrong preference for sons, itself
a reflection of deeply held andinequitable views of the intrinsic
value of men and women. In thesecontexts, women face extreme
pressure to bear sons and may
encounter violence, abandonmentor stigma for birthing girls
instead of boys. Under thesecircumstances, women havelittle power, voice or choice andtherefore little autonomy.
Gender inequality in law andpractice: Laws and policies often
reflect broader societal values
around gender and can interferewith autonomous decisions about
sexual and reproductive healthmatters. For example, a service
provider may be prohibitedfrom dispensing contraception
to adolescent girls or unmarried
women, or the criminalizationof same-sex relations may lead
members of the lesbian, gay,bisexual, transgender and intersex(LGBTI) community to avoid
seeking sexual and reproductive
health services.

Inherently relational
Sexual and reproductive decisions
and the role gender plays inmaking them are inherently
relational in that they involve
interactions with others,
particularly sexual or romantic
partners but also extended family
members, community members,
or institutions such as clinics andhospitals. Agency is experienced
by individuals within these
relationships (Figure 5.2).
In particular, three genderdependent aspects of relationships
are important in sexuality andreproductive decisions: the powerof the individual; voice, or the
degree to which individuals areable to articulate and advocate
for their needs and desires; andthe extent to which individuals
have real choices. Together, power,
voice and choice shape thedegree of agency an individual
has within a relationship,whether interpersonal or with an

FIGURE 5.2

Agency depends on relations
to individuals, communities
and institutions

INDIVIDUAL SRH RESOURCES:• Comprehensive knowledge• Physical and mental health• Self-efficiency• Critical consciousness

IMMEDIATE
RELATIONAL AGENCYIMMEDIATE RELATIONALSRH RESOURCES:

Characteristics of relationship(s)• Emotional intimacy• Communication quality• Respect for bodily integrity• Social support

DISTANTRELATIONAL AGENCYDISTANT RELATIONALSRH RESOURCES:• Political, legal, and policy
environment• Health system culture• Gender and reproductive norms• Physical, cultural and economic
environment

E
IC
VO

PO
WE
R

INDIVIDUAL AGENCY

LIFECOURSE

LIFECOURSECHOICE

Source: Edmeades and others, 2018.

© Mark Tuschman

The evolution of genderin family planning© Michele Crowe

institution or society. For example,
a woman may have considerable
agency in her immediate
relationship with her husband, buthave far less in her relationshipwith her health provider or evenher mother-in-law.
Agency is also determinedat different levels within eachrelationship. For example, atthe individual level, agency is
influenced by factors such as
knowledge about sexual andreproductive health and rights,
which can enable a person to more
effectively advocate for themself
and make informed choices. On
another level, agency is dependent
on factors such as the degree towhich a partner respects the other’sbodily integrity or the degree
to which there is freedom toexpress views about contraception.
At a more distant level, whererelationships are with institutions

78

CHAPTER 5

such as health systems or even theeconomy, agency depends on the
responsiveness to individual needs.
Within all these relationships,
gender norms are key. They canbuild—or undermine—agency inall aspects of life, but especially inmaking sexual and reproductive
health decisions.
Efforts to expand access tosexual and reproductive healthcare and empower individuals to
exercise their reproductive rights
can benefit from an approachthat does not just anticipate
what women need, but that also
takes into account that sexualand reproductive health decisions
are influenced by gender and theway it plays out in relationships,
including those with healthcare systems. Insights into
these dynamics can help service
providers better respond to theunique needs of each client.

The urgency with which
policymakers and donors viewed
the question of population growthin the late 1960s meant that many
early family planning programmes
were mainly about reducing
fertility, not about enabling
women to realize their right tomake decisions about the timing
and spacing of pregnancies.
Programmes in the 1960s and1970s therefore mostly focusedon providing contraceptives towomen, with little attention
paid to the needs or desires of
the women and men who might
actually use them or to the socialand gendered contexts within
which reproductive decisions
take place.
Some of these early programmes
were, at best, blind to gender, andat worst, partly responsible for
perpetuating gender inequalities
in the name of achieving greateruse of contraception and lower
fertility. The focus on women,
and particularly married women,
as the primary targets of familyplanning programmes served toreinforce existing gender norms
that assumed the primary rolesof women to be as wives andmothers.
Programmes usually reflected
the patriarchal societies inwhich they operated, with little
attention paid to the gender
dynamics around reproductive

CHAMPION OF CHANGE
For 35 years, Indian economist Gita Sen has pushed for feminist
thinking to play its rightful role at the centre of national andinternational commitments to reproductive and sexual healthand rights. As a leader of the feminist network Development
Alternatives with Women for a New Era, known as DAWN, Sen joins scholars and gender equality
advocates in deploying the tools of research and activism to push for gender justice.

Gita Sen“We have to make development work for women and girls,” Sen says. “And fight for women’s humanrights in every way we can.”Sen was prominent in mobilizing the global groundswell of civil society that forever shifted understandingof population and development at the 1994 International Conference on Population and Development(ICPD). Before that point, population conferences mostly involved men deliberating population targets.
Words like “sex” and “reproduction” were rarely heard. But at the ICPD, they met what Sen calls the“irresistible force of the women’s movement.” With thousands of activists participating from the global
South and North, women’s reproductive and sexual health and rights became the agenda.
“Twenty-five years later, the world is a much more difficult place for human rights. The backlash against
women and feminism has been huge,” Sen reflects. “But the fact that the ICPD agenda is still going tells
us about the strength of what we achieved.”
Sen has long argued that real change
for women will only come when
women mobilize to break down
existing power structures and shiftmodels of development. Amongother issues, that means reorienting
economies so that they no longer
depend on women’s unpaid carework or segregation into the worst
low-wage jobs. The goal should bemuch more than an equal shareof a “poisoned” pie.

“We have to makedevelopment work
for women and girls,
and fight for women’shuman rights in every
way we can.”About her lifetime commitment to gender equality,
she muses, “I think living the life of a woman drives me.
I was aware of gender inequality even as a girl, when a
lot was about controlling what girls could be and do.
The same did not apply to boys. Later, when I could
see how the structures of power and inequality
work in entire societies and economies—well,there was no going back.”© Suzanne Camarata© UN Photo/Milton Grant

decision-making or the general
well-being of women. Meanwhile,little programming was directed
towards men, aside from efforts toincrease condom use.
By the time of the 1974 World
Conference on Population,
governments, feminists and others
had begun to express frustration
with the demographic objectives
that had been driving much of
the international family planningmovement up to that point. The
growing evidence of violations ofreproductive and human rights,
the lack of input from thosemost directly affected by familyplanning programmes, as well as
the lack of recognition of broader
issues of social and economic80

CHAPTER 5

development in some familyplanning programmes contributed
to significant scepticism indeveloping countries about theintentions of the internationalfamily planning movement. This
scepticism resulted in a concerted
push by developing countries
to adopt a more comprehensive
approach to development that
included measures to empower
women to make their own
decisions about the number,
timing and spacing of births.
This push gained momentum
in the years that followed.
The United Nations Decadefor Women (1976–1985), forexample, coincided broadly
with three United Nations

world conferences on women(in 1975, 1980 and 1985), theestablishment of the United
Nations Development Fund for
Women (UNIFEM), and theConvention on the Eliminationof All Forms of Discrimination
against Women (CEDAW).
The networks formed along theway provided a foundation fora strong feminist alliance that
influenced the direction of thefamily planning movement forthe subsequent two decades.
At the International Conference
on Population and Development(ICPD) in 1994, the reproductive
rights movement took a great leap
forward. The agenda was led by
advocates for individual choices andGender and vulnerability: adolescents, sexual minorities andpeople with disabilities

The effect of gendered norms is most directly felt byPeople with disabilities

those groups for whom either control over sexuality

Women and young people with disabilities faceand reproductive behaviour is seen as particularly

multiple forms of discrimination including gender-

important or those whose behaviour does not conform

based discrimination. Data disaggregated by disability,

to prevailing social expectations. The effect on sexual

sex and age remain scarce but are indispensable forand reproductive health and rights canbe profound, with real consequences fortheir health.
Adolescents
Adolescence is a time of life when theforces of gender socialization, where boys
and girls learn how to behave in genderedways that are acceptable to society, areparticularly strong (John and others,2017). However, it is also a time when
individuals have particularly low levelsof power, voice and choice in their lives,
posing unique challenges to their accessto services (Patton and others, 2016).

understanding the situation of people with

Women andyoung people
with disabilities
face multiple
forms ofdiscrimination
includinggender-based
discrimination.

This is particularly true for girls.

disabilities and informing policies. Evidence
from around the world on sexual andgender-based violence and the sexual andreproductive health and rights of womenand young people with disabilities reveals
that their rights are at serious risk. Youngpeople with disabilities under the age of 18
are almost four times more likely than theirpeers without disabilities to be victims ofabuse, with young people with intellectual
disabilities, especially girls, at greatest risk.
Girls and young women with disabilities are
more likely to experience violence than either
their male peers with disabilities or girls andyoung women without disabilities.

Adolescents have special sexual and reproductive

Sexual minorities

health needs. They may lack knowledge about health

LGBTI individuals face additional barriers to sexual andmatters and how to access health care, restricting

reproductive health information and services. In mosttheir ability to prevent both pregnancy and sexuallysocieties, where sexual norms dictate heterosexualtransmitted infections. Social proscriptions against

behaviour with an emphasis on reproduction, thesesexual activity among adolescents, particularly for thoseindividuals face pervasive stigma and discrimination,that are unmarried, increase the social costs and stigma

often find their sexual practices criminalized, andassociated with seeking services, heighten fears aboutface high levels of sexual violence (Starrs and others,

loss of confidentiality while accessing services, and place2018). As a result, members of LGBTI communities

legal restrictions on free access to services. Finally, manyare often reluctant to disclose their sexual orientation

adolescents are married as children, a fundamental

or activities to health providers, inhibiting their ability

violation of their rights. These girls, even more thanto receive quality care that is reflective of their needs.

adolescents as a group, have been overlooked for much

This population continues to be marginalized withinof the history of the family planning movement, despite

the family planning movement, reflecting both direct

their obvious levels of need and relevance to the broader

prejudice and the perception that reproduction andgoals of the movement.

reproductive matters are not relevant to them.

STAT E OF WOR L D POPUL AT I ON 2 01 981

the full consideration of gender in
exercising reproductive rights.
In 2010, the United Nations
Entity for Gender Equality andthe Empowerment of Women(UN Women) was established tohelp realize the global objectiveof achieving gender equality
and women’s empowerment. In
2012, the World Bank focused
its annual World Development
Report specifically on genderinequality, declaring gender tobe at the heart of development,
and gender equality to have an
intrinsic value rather than being atool to achieve economic growthor other goals (World Bank, 2012).
And in 2015, the United Nations
endorsed the 2030 Agenda for
Sustainable Development andits accompanying 17 Sustainable
Development Goals, which include
a target for “universal access tosexual and reproductive healthand reproductive rights” andgreatly expand the number ofgender-related
indicators used
to monitor
progress.
Goal 5 aims
broadly toachieve genderequality andto empower women andgirls. It calls for, among otherthings, the integration of therecommendations of the ICPD
Programme of Action in national
plans, policies and programmes.

82

CHAPTER 5

Challenging the statusquo: moving towards
gender-transformational
programmes
Sexual and reproductive healthprogrammes that take into accounthow gender influences agency inthe context of relationships may
be better equipped to help womenand men exercise their reproductive
rights (Edmeades and others, 2018).
Tremendous progress has been
made in upholding reproductive
rights since 1969. Achieving future
success, however, requires directly
challenging the linkages between
gender and reproduction andthe patriarchal social norms thatreinforce them. Family planning
programmes, for example, havethe power to become agents ofgender transformation by building
understanding around gender inways that promote greater equality
and allow greater freedom insexual and reproductive choices. A
number of promising approaches
have been developed that point theway towards achieving these goals.
Achieving full equality must
involve engaging directly withmen as full, equitable partners inways that enable them to be bothinvested in their own health andsupportive of women’s autonomy(Hook and others, 2018).
Initiatives that have taken thisapproach include the Mobilizing
Men programme, which wasshown to reduce violence against
women in India, Kenya andUganda (Greig and Jerker, 2012).
Another example is MenCare,a programme developed by
Promundo and Sonke Gender
Justice. It aims to challenge
traditional norms aroundcaregiving, encouraging andenabling men to take on roles thatare not traditionally considered
masculine, with the goal ofachieving greater overall well-being,
gender equality and health. In asimilar vein, the Ecole des maris,or husbands’ schools, in Niger
have found considerable success inencouraging husbands to engage
in questions around sexual andreproductive health, both forthemselves and for their wives.
While engaging men in theprocess of gender transformationis critical to the long-term goalsof enhancing reproductive rights,
it is equally critical to continue
empowering women and girls
to reach their full potential. Of
the changes seen in the past two
decades in this regard, perhaps
none will have as much impact ongender norms in the long run as
the sharp increase in girls who areattending and staying in school.
The experience and content ofschooling can be a transformative
experience for girls in particular,enhancing their understanding of
their place in society and how thisis shaped; providing them with theskills and information to exercise
voice in their relationships withothers and negotiate for their own

CHAMPION OF CHANGE

Lise-Marie Dejean“I grew up in an atmosphere where women’s lives
were always put aside,” Lise-Marie Dejean remembers.
“Women were constantly reminded by men and tended
to believe that their bodies did not belong to them.”

Her voice animated, she continues: “We had to deconstruct the myths and mentalities. We had to help
women take care of their bodies and their health.”
Widely renowned in Haiti as a defender of women’s rights, Dejean, 75, was born not long after the 1934
founding of the country’s first feminist organization, which fought for women’s rights to education andpolitical participation, including to vote. Dejean remembers going to women’s meetings with her mother.
But it was not until she became a doctor and started looking at the extremely high maternal mortality rates
in Haiti that she fully grasped the magnitude of gender discrimination and the lack of reproductive rights.
Dejean decided to take her medical skills to some of the poorest and most remote regions of Haiti, seeing
individual patients and educating midwives to extend available medical services. Later, as the head of amajor Haitian women’s organization—Solidarite
Fanm Ayisyèn or SOFA—she helped open
women’s clinics in crowded urban slums. An
ongoing advocacy plank has been a push toremove criminal penalties for abortion. Illegal,
unsafe abortion, Dejean points out, accounts
for about a third of the maternal mortality rate.
“This is a fight for women’s lives,” she stresses.

“It’s a beautiful gain. When a personis psychologically ready to defend
herself as a human being, that’s a big
victory. She won’t get lost. She won’t
allow anyone to walk over her.”For Haitian women, the 1994 International
Conference on Population and Development
was a watershed moment. One key outcome
was the creation of the first national women’saffairs ministry, led by Dejean. She had to
overcome death threats and demonstrations to
get it running, and even now, constant vigilanceis required in the face of regular suggestions toshut it down.
Dejean is undaunted. “Women are beginning
to represent themselves as people with rights,”
she says. “It’s a beautiful gain. When a personis psychologically ready to defend herself as ahuman being, that’s a big victory. She won’t get
lost. She won’t allow anyone to walk over her.”© UNFPA/M. Bradley

CHAMPION OF CHANGE
As a younger feminist activist,
Sivananthi Thanenthiran used
to think that reproductive rights
battles had mostly been won
in the 1960s. Enough focus had been put on women and their bodies. She chose instead to take partin seminal initiatives like the Women’s Candidacy Initiative in her native Malaysia. It backed politicalcandidates running on women’s rights issues.

Sivananthi Thanenthiran

But in 2006, as she worked on a book on reproductive health in Asia, she began looking at numbers
and speaking to people, and became outraged.
“It was really shocking to me that these battles were still very alive and present. I needed to dosomething about it.”Thanenthiran joined activists at the Asian-Pacific Resource andResearch Centre for Women (ARROW), eventually becoming
the organization’s Executive Director. Active in 17 countries,
ARROW advocates for the full realization of women’s sexualand reproductive health and rights so that they can be equalcitizens in all aspects of life.

“You only get what you
fight for. We need to put ourperspectives out there andforge ahead, fearlessly.”

From social media to the halls of international political talks,Thanenthiran has become a prominent voice in systematicallytracking gaps in sexual and reproductive rights as well as
making links to issues that worsen the shortfalls, such as
poverty and climate change. In a fragmented and deeply
unequal world, she mobilizes people and policymakers topush back against what she calls the “bargaining” awayof social rights amid a struggle over increasingly scarce
economic and other resources.
Thanenthiran is proud of young feminists now stepping up to
take on the mantle of the movement, including at ARROW.
They have inherited a world where gender equality is more
widely recognized than it ever has been.
But the battle is far from over, she cautions. Much depends
on being bold while remaining united. “You only get what you
fight for. We need to put our perspectives out there and forge
ahead, fearlessly.”© The Asian-Pacific Resource & Research Centre for Women (ARROW)

interests; and protecting them fromharmful practices such as childmarriage. Other programmes, suchas the Abriendo Oportunidades in
Guatemala, implemented by the
Population Council, have also
found success in helping girls
successfully navigate the transition
to adulthood, thus literally opening
up opportunities that may shape
the remainder of their lives.
Comprehensive sexuality
education, too, is helping
transform gender norms throughage-appropriate curricula thatprovide information about
sexuality and reproduction but that
also focus on gender and power

in relationships. UNESCO andUNFPA support comprehensive
sexuality education in schools andthrough community organizations
in dozens of developing countries(Haberland, 2015). Encouraging
boys and girls to openly discussquestions around sexuality will
result in more communicative
partnerships where both partners
feel free to share their desires
and preferences in a mutuallyrespectful manner, enhancing both
the relationships of women andmen and improving reproductive
outcomes.
Achieving the broader goal of
empowerment for all will require

the sexual and reproductive
health community to make arenewed commitment to building
a deeper understanding of therole of gender and how genderedroles and expectations shapesocial interactions in matters of
sexual and reproductive health.
Only by addressing these root
causes will the field be able to
finally claim to have effectively
liberated humanity from what
Goldberg (2009) describes as
the “intertwined tyrannies ofculture and biology,” an effort
that remains one of the mostambitious undertaken inhuman history.

CHAPTER HIGHLIGHTS•

Of all the obstacles to the achievement and exerciseof human rights, including reproductive rights, few
have proven to be as challenging to overcome as
those based on gender.

•

Gender, the web of expectations and norms withina society that together define what are appropriate
male and female behaviours, roles and characteristics,
is learned, internalized and reinforced through social
interactions with others, thus having a profoundinfluence on every domain of life.

•

Gender inequality limits the ability of women to
freely make fundamental decisions about when andwith whom to have sex, about the use of contraception
or health care, and about whether and when to seek
employment or whether to seek higher education.

•

Gender norms constrain the reproductive rights ofmen by creating strong social pressures to prove
fertility, engage in risky behaviours, and have
many children.

•

Gender-unequal norms and expectations magnify
the negative effects of other impediments to rights
and choices.

•

Sexual and reproductive decisions and the role
gender plays in making them are inherently
relational in that they involve interactions withothers, particularly sexual or romantic partners
but also extended family members, community
members, or institutions such as clinics andhospitals.

•

Reproductive rights cannot be fully realized in theabsence of greater gender equality.

•

Sexual and reproductive health programmes thattake into account how gender influences agency inthe context of relationships and seek to promote
greater equality are better equipped to help both
women and men exercise their reproductive rights.

STAT E OF WOR L D POPUL AT I ON 2 01 985© Brian Sokol/Panos Pictures

CHAPTER 6

WHEN SERVICESCOLLAPSE
Since the mid-1990s, governments, aid organizations
and international institutions have increasingly delivered
services to women and adolescent girls whose choices
have been constrained by wars and natural disasters.

In the twenty-first century, as longrunning conflicts have proliferated
and climate-related disasters haveintensified, international consensus
on this priority has deepened.
States have approved successivecommitments to address reproductive
health concerns and gender-based
violence in crisis settings, andresponders have honed expertiseon life-saving practices.

A world of trouble
The world today faces unprecedented
levels of humanitarian need.
Worldwide, some 136 million people
were in need of humanitarian aid
in 2018; 91 million received aid in2017 (OCHA, 2018).

Numbers of refugees, migrants
and internally displaced people
have mounted steadily in recent
years. Factors driving the increase
include long-running conflicts thatstem from and exacerbate countries’
fragility; deadly storms related toclimate change; and unpredictable
events like earthquakes.
The breakdown in security, lossof shelter and disruption of water,
food, sanitation and health services
all combine to create enduringhardship for people affected bycrises. Many are compelled to moveand undergo additional suffering
during the journey. Others languishin refugee settlements, sometimes
for decades.

Every day, more than 500 womenand girls in countries with emergency
settings die during pregnancy andchildbirth, due to the absence ofskilled birth attendants or emergency
obstetric procedures, and due tounsafe abortions (UNFPA, 2018b).
Insecurity and dislocation increase
vulnerabilities to rape, exploitationand HIV acquisition, including
among women, adolescent girls andboys, disabled people and individuals
identifying as lesbian, gay, bisexual,
transgender or intersex.
The causes and severity ofdisplacement vary considerably
between and within countries, but it
is invariably the least advantaged who
suffer hardest and longest. “Poverty

STAT E OF WOR L D POPUL AT I ON 2 01 987and inequality, political instability
and state fragility, water stress andfood insecurity, climate change
and environmental degradation,unsustainable development andpoor urban planning combine indifferent ways in different countries
to increase people’s exposure andvulnerability,” according to theInternal Displacement Monitoring
Centre. Notably, it states, “low levelsof human development correlatestrongly with disaster displacementrisk” (IDMC, 2018).
Data consolidated by United
Nations agencies, the European
Commission, governments andnon-governmental organizations
show that the risk of humanitariancrises and disasters that could
overwhelm national response
capacities is high in at least
12 countries. (Figure 6.1; IASC andEuropean Commission, 2019).

Protracted crises:
the new normal
Wars have always impacted
civilian populations and frequently
produced mass displacements.
In 1969, as UNFPA was coming
into being, the Biafran War was
precipitating a massive famine andhumanitarian crisis. In 1994, theyear of the International Conference
on Population and Development(ICPD), conflict in the former
Yugoslavia and civil war in Rwanda
involved massive attacks on civilians.
Today, “protracted crises are
the new normal,” according to the© Ali Arkady/VII/ReduxFIGURE 6.1

Humanitarian crises and disasters could overwhelm countries’ response capacity

The 2019 INFORM Global Risk Index is made up of three dimensions—hazards and exposure,vulnerability and lack of coping capacity. This map shows details for the 12 countries with thehighest overall risk. Legend is based on the INFORM 2019 Global Risk Index database.

Sudan

Syria

Iraq

Afghanistan

3-year trend:
Hazard: 7.3
Vulnerability: 6.9
Lack of coping
capacity: 7.0

3-year trend:
Hazard: 8.6
Vulnerability: 7.4
Lack of coping
capacity: 5.7

3-year trend:
Hazard: 8.6
Vulnerability: 6.1
Lack of coping
capacity: 7.0

3-year trend:
Hazard: 8.8
Vulnerability: 7.2
Lack of coping
capacity: 7.5

Risk: 7.1

Risk: 7.1

Risk: 7.2

Risk: 7.8

Chad

Risk: 7.2

3-year trend:
Hazard: 5.5
Vulnerability: 7.6
Lack of coping
capacity: 8.9

Nigeria
Risk: 6.8

3-year trend:
Hazard: 7.2
Vulnerability: 6.6
Lack of coping
capacity: 6.6

Central African Republic

Yemen

Risk: 8.5

Risk: 7.8

3-year trend:
Hazard: 7.9
Vulnerability: 8.8
Lack of coping
capacity: 8.7

3-year trend:
Hazard: 8.1
Vulnerability: 7.5
Lack of coping
capacity: 7.9

Democratic Republicof Congo
Risk: 7.6

South Sudan
Risk: 8.93-year trend:
Hazard: 8.2
Vulnerability: 9.2
Lack of coping
capacity: 9.3

3-year trend:
Hazard: 7.1
Vulnerability: 7.6
Lack of coping
capacity: 8.0

Ethiopia

Somalia

Risk: 6.8

Risk: 9.1

3-year trend:
Hazard: 9.0
Vulnerability: 9.2
Lack of coping
capacity: 9.0

3-year trend:
Hazard: 7.2
Vulnerability: 6.6
Lack of coping
capacity: 6.6

INFORM RISK INDEXKEY

Increasing risk
Very low
0–2

Low
2.1–3.5

Medium
3.6–5

High
5.1–6.5

Very high
6.6–10StableDecreasing risk

Not included
in INFORMSTAT E OF WOR L D POPUL AT I ON 2 01 9

89

Global Humanitarian Overview
2018 of the United Nations
Office for the Coordination of
Humanitarian Affairs (OCHA,
2018). Long-term dislocation due
to intractable conflicts has driven
the unprecedented increase ininternally displaced people, refugees
and migrants in recent years,
creating ever-growing needs forassistance and a mounting challenge
for humanitarian actors.
In eight years, the civil war in the
Syrian Arab Republic has displaced
more than half of the country’s
population.
At the end of 2017, there
were 2.6 million refugees fromAfghanistan, 2.4 million from South
Sudan, and nearly 1 million from
Somalia (UNHCR, 2018).
© Lynsey Addario/Getty Images

The world’s largest
humanitarian crisis today is in
Yemen, where war has caused
the economy, social services andlivelihoods to collapse. Four outof five people, 22 million, arein need, many on the brink offamine (OCHA, 2018).
Around the world, nearly
12 million people were newly
displaced by armed conflict,terrorism and communal orpolitical violence in 2017, up
from 6.9 million the previous
year; 18 million were uprooted byweather-related disasters (IDMC,
2018). At the start of 2018,
there were 40.3 million peopleinternally displaced by conflict and22.5 million refugees—the highest
numbers ever seen (IOM, 2017).

Conflict was a major elementin 19 of the 21 situations where
the United Nations coordinatedhumanitarian response plans in
2018. Most of these crises havegone on for five years or more; three(in the Democratic Republic of theCongo, Somalia and Sudan) havepersisted for over 18 years (OCHA,
2018). The number of forcibly
displaced people has risen by over
50 per cent in the past decade.
In 2017, ethnic violence forced
655,500 Rohingya people to flee
Myanmar into Bangladesh. In thesame year, 2.9 million Syrians,
2.2 million Congolese and1.4 million Iraqis were newly
displaced by conflict (IDMC, 2018).
The effects of protracted
internal or external conflict canpersist long after hostilities end. In
2017, the world’s largest displaced
population— 7.7 million people—
were living in Colombia, despite
the achievement of a peace deal
in 2016.
Extensive conflict often results
in a breakdown of authority andeconomic collapse, necessitatinglarge-scale humanitarianassistance. Security threats torelief workers increase thechallenges. Affected people ininsecure places of refuge remain
vulnerable to new outbreaks ofviolence and displacement, andeach round makes them lessresilient (IDMC, 2018).
Those who flee violence are
more likely to remain in their own
countries than to cross borders.

FIGURE 6.2

Flood

Poverty and hardship are expected
to increase in some areas as global
warming increases, contributing tofurther displacement. Indigenous
peoples and local communities
dependent on agricultural or coastal
livelihoods, particularly in least
developed regions, are especiallyvulnerable.
Climate change is also believed to
be a risk factor in outbreaks of infectious diseases like Ebola and Zika,
through the spread of disease vectors
and competition between humans
and animals for dwindling habitatand resources (Deese and Klain,2017). Epidemics in West Africa andmore recently in the Democratic
Republic of the Congo have haddevastating impacts in communities
already incapacitated by conflict.

Many long-term displaced people
settle among host communities,
often in urban areas, straining
services and complicating
relief efforts.

Climate-related
disasters
More people are displaced byfloods, storms, droughts andwildfires than by conflict, thoughmany of these evacuations are shortterm. Since 2008, new weatherrelated displacements worldwide
have averaged around 25 million
per year; typhoons and hurricanes
are a leading cause (Figure 6.2).
Small countries and island Statesin particular face increasing risksof economic and social devastation
due to disasters (IOM, 2017).

Disasters by type, 1969–2017
Storm

Drought

240
Number of disasters per disaster type

220
200
180
160
140
120
100
80
60
40
20
0

1969

1972

1975

1978

1981

1984

1987

1990

1993

1996

1999

2002

2005

2008

2011

2014

2017

Year
Source: EM-DAT: The Emergency Events Database – Unversité catholique de Louvain (UCL) – CRED, D. Guha-Sapir – www.emdat.be, Brussels, Belgium

STAT E OF WOR L D POPUL AT I ON 2 01 9

91

Millions on the move
Displacement fuelled by conflictand desperation has contributed
to a dramatic rise in international
and internal migration in recent
years. While refugees and internallydisplaced people are a relatively
small percentage of all migrants,
they frequently find themselves inhighly vulnerable situations andmost often need assistance andprotection (IOM, 2017).
Migrants displaced by conflictin the Middle East and Africa
have endured particular hardship.
Thousands have died attempting
to cross the Mediterranean. The
closure of transit routes in Europe
and the resort to smugglers has
exposed many migrants to risks of
exploitation or human trafficking(IOM, 2017).

Women and adolescentsat risk
Every humanitarian crisis—
whether due to conflict or natural
disaster—causes systems to break
down, increasing multiple needs forprotection and services. Especiallyin the initial rush to provide
food and shelter, responders may
overlook the particular ways a crisis
can increase the vulnerability ofwomen and girls and threaten
their lives.
Experiencing a natural disaster or
fleeing violence can be extremely
harrowing for pregnant womenand mothers of small children.
Trauma and malnutrition are

92

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dangerous during pregnancy, andduring emergencies many women
miscarry or deliver prematurely.
The lack of even basic conditions
for a clean delivery increases
the risk of a fatal infection
for both mother and child(UNFPA, 2004). Complicationsof childbirth in the absenceof skilled birth attendants or
emergency obstetric care often
lead to death or serious injury
such as obstetric fistula.
In the world’s most densely
populated refugee settlement at
Cox’s Bazar in Bangladesh, only
one in five Rohingya mothers
gives birth at a health centre,
although there are facilities staffedby dozens of trained midwives.
Some women are reportedly
prevented by their husbands fromgoing outside their makeshift
homes; others who have been
raped are said to fear stigma anddiscrimination from the wider
community (UNFPA Bangladesh,2018).
The disruption of familyplanning is also life-threatening.
Sexually active women without
access to contraceptives, due
to a lack of services or legal
restrictions, risk unintended
pregnancy and sexuallytransmitted infections includingHIV. Many who become pregnant
resort to unsafe abortion, aleading cause of maternal deathand injury. Safe abortion services
are often minimal or non-existentin crisis settings, even where
allowed under the law, and lifesaving post-abortion care is often
unavailable.
Conditions of displacement
and the disruption of families
make women and girls susceptible
to rape and assault. Adolescent
girls, the disabled, and ethnic
and sexual minorities may beespecially at risk. Recent research
indicates that at least one in fiverefugees or displaced women incomplex humanitarian settings
have experienced sexual violence,
though it is often unreported(Vu and others, 2014). Survivors
suffer psychological andphysical trauma, as well as
unwanted pregnancies andsexually transmitted infections,
including HIV.
People with disabilities are
particularly vulnerable to sexual
violence, and may have moredifficulty accessing help after
an attack. Men and boys arealso at risk, and the norms that
discourage women and girls
from reporting assaults can beeven more of a deterrent tocoming forward in their case
(IFRC, 2018).
Fear of sexual assault or
exploitation and abuse restrict
the mobility of many refugee anddisplaced women. Some families
in dire circumstances resort tochild marriage, hoping thatmarrying their daughters off willprotect the girls from violence.

CHAMPION OF CHANGE
Newly married at the age of 21, Nadine Alhraki wasstudying geography in a university in Damascus, Syria,
six years ago. Since then, she has been a refugee.
As Syria descended into war and chaos, she and herhusband joined 5 million people fleeing their country. Across the border in Jordan, they found safety
in the sprawling Za’atari Refugee Camp.

Nadine Alhraki

Three days after she arrived, despite wrenching personal upheaval, Alhraki signed on as a volunteer
with Questscope, a humanitarian organization that serves young people. A workshop trained her
to teach and mentor youth and adolescents on reproductive health. “These are important issues for
all people, refugees or not,” Alhraki says. “In our own community, we know there is a gap in correct
information and young people getting the services they need.”
At a Questscope youth centre, Alhraki leads education sessions taking up issues such as safe
motherhood for young men and women aged 18–24, and the stages of puberty for those under age
18. Maintaining a friendly atmosphere is part of encouraging interactive discussions around practicalquestions, such as what to do when your period starts. The sessions often mark the first time thatyounger camp residents have had any information about reproductive health.
“When people realize they have had the wrong information, and hear the right information and how that
can impact their life, it makes a huge change,” Alhraki says.
Sessions empower youth to challenge stereotypes, including those related to gender, and to think up
and act on their own ideas. In one activity that Alhraki remembers well, young people distributed baby
slings to mothers and fathers, along withmessages about how husbands can help
their wives in caring for children.

“When people realize they have
had the wrong information, andhear the right informationand how that can impact
their life, it makes ahuge change.”

Now pregnant with her first child, Alhraki
is determined to keep helping young
residents of Za’atari. But her biggest
dream is that her own child will not haveto grow up as a refugee. And that he or
she will enjoy full access to quality healthservices and education, and complete
awareness of reproductive health.
On the last, she laughs. “Of course, I willteach my child all I know, now that I’man expert!”© Helal KhlaifDeveloping a response
grounded in rights andchoicesIn the humanitarian response to
emergencies around the world,
women’s needs and vulnerabilities
have not always received the samelevel of attention as the need forfood and shelter.
It was only in the 1990s thathumanitarian actors adopted amore consistent focus on therights and needs of crisis-affected
women and girls (Chynoweth,
2015). The first edition of the
Handbook for Emergencies issued
by the Office of the United
Nations High Commissioner for
Refugees (UNHCR) in 1982 hadstipulated that primary health carefor displaced communities should
include “maternal and child care,including family planning.” Inpractice, however, contraceptive
services were not typically included
in refugee health care (Wulf, 1994).
In 1991, UNHCR issued
Guidelines on the Protection of
Refugee Women, which framed protection concerns within establishedinternational norms including the
Universal Declaration on Human
Rights and the Convention on
the Elimination of All Forms ofDiscrimination Against Women.
In addition to “protection against
forced return to their countriesof origin; security against armed
attacks and other forms of violence;protection from unjustified andunduly prolonged detention; a94

CHAPTER 6

legal status that accords adequate
social and economic rights; andaccess to such basic items as food,shelter, clothing and medical care,”it noted, “refugee women and girls
have special protection needs thatreflect their gender: they need, forexample, protection against manipulation, sexual and physical abuseand exploitation, and protection
against sexual discrimination in
the delivery of goods and services”(UNHCR, 1991).
The Women’s Commission for
Refugee Women and Children in
1994 published Refugee Women andReproductive Health Care: Reassessing
Priorities. This influential report
identified critical gaps in care forwomen, including sex education,family planning, HIV education andprevention, supplies for menstruating
women, and services to assist
survivors of sexual abuse, rape andforced prostitution (Wulf, 1994).
The transformational ICPD in
1994 elevated global recognitionof women’s agency with regard
to sex and reproduction. In its
recommendations on realizing
reproductive health and rights,
the ICPD Programme of Action
included displaced people,
refugees and migrants affected byenvironmental degradation, natural
disasters and internal conflicts, andcalled on States to address the root
causes, “especially those related topoverty.” It called for protectionof people who, “given the forced
nature of their movement … often

find themselves in particularly
vulnerable situations, especiallywomen, who may be subjected
to rape and sexual assault insituations of armed conflict.” It
urged governments “to ensure thatinternally displaced persons receive… basic health-care services,
including reproductive healthservices and family planning” andto provide refugees with “healthservices including family planning”(United Nations, 2014a).
In 1999, a five-year review
of progress in implementing theProgramme of Action elaborated
on the need to address protection
concerns and ensure the sexualand reproductive health ofrefugees and displaced people(United Nations, 1999).

Setting standards forreproductive health care
In 1995, some 40 intergovernmental and government agencies andnon-governmental organizations
involved in relief work formed theInter-Agency Working Group on
Reproductive Health in Refugee
Situations, now the Inter-Agency
Working Group on Crises. The
coalition, spearheaded by UNFPA
and UNHCR, developed guidelines for interventions at different
phases of crises; on safe motherhood; sexual and gender-based
violence; sexually transmitted
diseases, including HIV; andfamily planning. These were
elaborated in Reproductive HealthWhile refugees andinternally displaced
people are a relatively
small percentage of
all migrants, theyfrequently findthemselves in highly
vulnerable situations
and most often
need assistanceand protection.

© UNFPA/N. Batev

in Emergency Situations:
An Inter-agency Field Manual(UNHCR, 1999).
The stated cornerstone of
the manual was the principle:“Reproductive health care should
be available in all situations and bebased on the needs and expressed
demands of refugees, particularly
women, with full respect for thevarious religious and ethical values
and cultural backgrounds of the
refugees while also conformingwith universally recognizedinternational human rights.”
Over the years, the Inter-Agency
Working Group on Crises has been
instrumental in pressing for the
inclusion of sexual and reproductive
health concerns in all crisis response,and in providing technical standards

for service delivery and evidence
for policymakers. The coalition
has grown to include 20 steeringcommittee member agencies and has
a network of over 2,000 members
from 450 agencies.

Essential services ina crisis
In its field manual, the working
group delineated an influential“minimum initial service package”
of activities most crucial topreventing mortality and morbidity.
These apply in all emergencies, andshould be implemented by trained
staff at the start of any crisis.
The objectives are to: identify
a lead agency to coordinate
reproductive health activities andsupport partners; prevent sexual

violence, and provide medical andpsychosocial care for survivors;
reduce HIV transmission, withsafe blood transfusion and freecondoms; prevent maternal
and newborn deaths, throughemergency services, full-timereferrals and clean delivery kits;
prevent unintended pregnancies,
with a range of contraceptive
methods and information; andtransition to comprehensive sexualand reproductive health services assoon as possible.
Advocacy by working group
partners has led to broad adoptionof the service package. It is now
included in the Sphere Standards,
widely adopted principles forhumanitarian responders; in thelife-saving criteria of the United

STAT E OF WOR L D POPUL AT I ON 2 01 9

95

Nations Central Emergency
Response Fund for prioritizing
early action in disasters; and in
health guidance from the InterAgency Standing Committee,
which coordinates relief work by
United Nations agencies andnon-governmental organizations(IASC, 2009).
The 2018 revision of the fieldmanual now identifies preventing
unintended pregnancy—by
providing both long- and shortacting contraceptive methods,
information and counselling—
as a distinct, life-saving objective
rather than an element of maternal
health. Control of fertility isalso recognized as enabling
women and girls to engage ineducation, protection, life skills
and livelihoods. Safe abortion care,
where legal, is included as a separate
priority. The manual also provides
more guidance on the transition
from emergency to comprehensive
sexual and reproductive healthservices, adds a logistics chapter,and places greater emphasis on
gender-based violence.
Importantly, the 2018 manualemphasizes that providing
comprehensive sexual andreproductive health services
for crisis-affected populations
is a human rights imperativealigned with international rights
obligations and guidance fromnumerous political bodies.
The United Nations World
Humanitarian Summit in Istanbul

96

CHAPTER 6

in 2016 adopted the Agenda for
Humanity. As part of its corecommitments to achieve genderequality, it called for “universal
access to sexual and reproductive
health and reproductive rights,”
and a “coordinated global
approach to prevent and respondto gender-based violence in crisis
contexts.” States made numerous
commitments to implement andfund sexual and reproductive
health activities.

Responding to sexual
violence
In parallel to the growing emphasison ensuring the sexual andreproductive health of women in
emergencies, humanitarian actors
have focused increasingly on sexual
violence and its consequences,
particularly during conflict. The
horrific, widespread use of rape asa weapon of war in the 1990s in
the former Yugoslavia, Rwanda,
Sierra Leone and Liberia, and in
the Democratic Republic of theCongo after 1998, prompted theinternational community
to respond.
The 1995 Beijing Declaration
and Platform for Action adopted
at the Fourth World Conferenceon Women called for measures toaddress the “close link between
massive violations of humanrights, especially in the formof genocide, ethnic cleansing,systematic rape of women in war
situations and refugee flows andother displacements, and thefact that refugee, displaced andreturnee women may be subject
to particular human rights abuse”(United Nations, 1995a).
The 1998 Rome Statuteestablishing the International
Criminal Court defined rape andsexual violence committed insystematic attacks against civilian
populations as crimes against
humanity and war crimes(ICC, 1998).
In 2000, the United Nations
Security Council adopted
resolution 1325 calling forincreased women’s participationin conflict prevention and thepromotion of peace and security.
The resolution called on “all parties
to armed conflict to take special
measures to protect women andgirls from gender-based violence,
particularly rape and other forms
of sexual abuse.”
Security Council resolution
1820, adopted in 2008, declaredthat “women and girls are
particularly targeted by the useof sexual violence, including
as a tactic of war to humiliate,
dominate, instil fear in, disperse
and/or forcibly relocate civilian
members of a community or ethnic
group.” The resolution calledsexual violence a threat to security
and an impediment to restoring
peace, and said that post-conflictreconstruction and recovery efforts
need to pay special attention to
the effects of sexual violence. The

Council elaborated on these issues
in subsequent resolutions.
Over the same period,organizations involved in relief
work have increasingly prioritized
preventing sexual violence andresponding to the needs ofsurvivors, a core objective of theminimum initial service package.
The revised field manual of theInter-Agency Working Groupdefines gender-based violence as
including rape, sexual exploitation
and abuse, forced prostitution,
trafficking, forced early marriage,
female genital mutilation, honour
killing, domestic and intimate
partner violence, harm basedon sexual orientation or gender
identity, and elder abuse. It offers
guidance on establishing safe
© SOPA Images/Getty Images

spaces for survivors within healthfacilities, providing appropriate
clinical care, and referring
survivors to psychosocial andlegal services.

Global compacts on
migrants and refugees
The United Nations General
Assembly hosted the Summit on
Refugees and Migrants, the firstof its kind, in 2016. The aim wasto develop a blueprint for a more
responsible, predictable system
for responding to migration.
In its New York Declaration,
the Assembly affirmed that theUnited Nations 2030 Agenda for
Sustainable Development promise
to “leave no one behind” includes
refugees, internally displaced

people and migrants. Member
States pledged to “ensure apeople-centred, sensitive, humane,dignified, gender-responsive andprompt reception for all persons
arriving in our countries” andprotect their human rights andto increase diplomacy aimed atearly prevention of crises. They
committed to “mainstream agender perspective” in migration
policies, to “combat gender-based
violence,” and to “provide access tosexual and reproductive health-careservices” to those affected by crises(United Nations, 2016).
The summit kicked off
negotiations to develop two moreextensive agreements: the Global
Compact on Refugees, which the
General Assembly endorsed in© UNFPA Myanmar/B. Manser

its 2018 session; and the Global
Compact for Safe, Orderly andRegular Migration, adopted at
an intergovernmental conferencein Marrakech, Morocco, in
December 2018. Both compacts
have commitments to combating
gender-based violence. Neither
document, however, explicitly
mentions sexual and reproductive
health care (United Nations, 2018and 2018a).

UNFPA responding inemergencies
In line with its mandate set forthin the ICPD Programme of Action,
UNFPA focuses on the sexual andreproductive health and rights ofwomen and girls, even in crises
and emergencies.
UNFPA has advocated forincluding reproductive healthinterventions as a life-saving
component of international
assistance in all crises and has
been instrumental in developing

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standards that today underpin
the work of responding to
reproductive health needs andgender-based violence in a wide
range of settings. It has helped
recovering countries integrate
reproductive health as they rebuild
their health systems. And it ishelping countries prepare to face
future crises.
Before crisis strikes, andthroughout prolonged emergencies,
UNFPA, in partnership withgovernments and local civil society
organizations, helps build capacities in health systems, by stocking
critical supplies, strengthening
supply-chain management, andtraining national staff in storing,transporting and using reproductive health supplies.
When an earthquake hit
Nepal in 2015, responders wereable to quickly deploy medical
supplies pre-positioned in strategic
locations. Warehouses in Fiji andAustralia stand ready to serve thedisaster-vulnerable Pacific Islands(UNFPA, 2018c). In South Sudan,
where few health facilities arefunctional, five supply hubs stock
post-rape kits and reproductive
health supplies (UNFPA, 2018c).
Worldwide, UNFPA is the main
provider of reproductive healthrelated supplies and equipment
packaged and ready for distribution
for different situations and levelsof service. Family planning kits,
for example, contain condoms,
oral and injectable contraceptives,and intrauterine devices.
Maternal and neonatal healthkits include medical equipment
and supplies essential for clinicaldelivery assistance and basic andcomprehensive emergency obstetriccare. Other kits contain supplies
for treating sexually transmitted
infections, managing miscarriages,
and performing blood transfusions.
UNFPA gives priority in crisis
situations to meeting the sexualand reproductive health and protection needs of adolescent girls.
UNFPA and Save the Children
in 2009 published a toolkit on
responding to adolescents’ needs
through the minimum initial service package (UNFPA, 2009).
In its humanitarian interventions, UNFPA sets up dedicatedspaces for girls, offering livelihood
skills, health information andreferral to services. Where needed,
it also supports mobile clinics andoutreach teams providing healthservices and supplies, includingcontraceptives. Adolescents are
consulted and participate in the
response, distributing dignity kits,collecting data and communicatingwith peers (UNFPA, 2016).
UNFPA also coordinates gender-based violence prevention, risk
mitigation and response in many
humanitarian settings. It trains
health workers to sensitively andconfidentially provide quality,
life-saving services including postrape treatment, and distributes
clinical supplies—including for
emergency contraception and HIV
post-exposure prophylaxis—tohealth centres and mobile clinics.

Building resilience
Ensuring the sexual andreproductive health and rights

and the safety of women andgirls in crises is now a wellestablished global priority. But
real success in this effort is boundup with meeting the Sustainable
Development Goals for 2030.
Societies need to be made more
resilient to prevent, confront
and recover from violence anddisasters. That calls for moreresources, smarter solutions andbetter international collaboration
to address multiple factors
underlying the exponential growthin humanitarian needs. Growing
inequality, prolonged conflicts,
climate change and demographic
developments (population
growth, migration, urbanization
and ageing) all make it harder toovercome the mounting challenges.

And well beyond crisis-responsedemands, vast investments andgreater commitment are needed
for sustainable development,
peacebuilding, addressing climatechange, and disaster risk reduction.
As a 2016 United Nations
Secretary-General’s expert panel
on humanitarian financing noted:“The best way to deal withgrowing humanitarian needs is
to address their root causes …
Because development is the best
resilience-builder of all… theworld’s scarce resources of official
development assistance (ODA)should be used where it mattersmost—in situations of fragility”(United Nations, 2016a).

CHAPTER HIGHLIGHTS•

Every humanitarian crisis—whether due to conflictor natural disaster—causes systems to break down,
increasing multiple needs for protection and services.
Especially in the initial rush to provide food andshelter, responders may overlook the particular
ways a crisis can increase the vulnerability ofwomen and girls and threaten their lives.

•

Experiencing a natural disaster or fleeing violence
can be extremely harrowing for pregnant women andmothers of small children. Trauma and malnutrition
are dangerous during pregnancy, and during
emergencies many women miscarry or deliver
prematurely.

•

Every day, more than 500 women and girls incountries with emergency settings die during
pregnancy and childbirth, due to the absence ofskilled birth attendants or emergency obstetric
procedures, and to unsafe abortions.

•

Since the mid-1990s, governments, aid organizations
and international institutions are increasingly
delivering services to women and adolescent
girls whose choices have been constrained bywars and natural disasters.

•

The transformational International Conference
on Population and Development in 1994 elevatedglobal recognition of women’s agency with regard
to sex and reproduction. In its recommendations
on realizing reproductive health and rights, theconference’s Programme of Action included
displaced people, refugees and migrants affectedby environmental degradation, natural disasters
and internal conflicts.

STAT E OF WOR L D POPUL AT I ON 2 01 9

99© Andrea Bruce/NOORCHAPTER 7

INSTITUTIONS AND
FUNDING TO ENSURE
RIGHTS AND CHOICESIn 1969, few countries had population policies or institutions to
implement them (Nizamuddin, 2002). But as global attention
to population issues took root, more and more countries sought
to better understand and address the interactions between
population dynamics and development.
By 1976, 40 countries had policies tolower fertility; by 1986, that number
had grown to 54, and by 1996, 82(United Nations, 2015a).
Some countries put their ministriesof health in charge of narrowly
focused programmes to deliver
contraceptives. Others establishedindependent family planningboards or population commissions
to rapidly translate donor funding
into services. And in many othercountries, governments collaborated
with civil society organizations todeliver contraceptives, particularly tounderserved populations.

Over time, institutions have had to
adapt to be able to meet the growing
needs for a broader range of sexualand reproductive health services andto enable women to exercise theirreproductive rights.

Early constraints
Some early family planning
programmes housed within
ministries of health delivered services
mainly through urban clinics andhospitals. Weak infrastructure
sometimes made it difficult to extend
services to remote areas. And evenin urban areas, under-resourced

facilities and a lack of trained
personnel meant that large swathesof the population in a given country
had limited or no access to quality
contraceptive services.
Further, because Western donors
covered many of the costs ofdispensing contraception at thattime, services often reflected donor
preferences and, in the process,sometimes failed to respond to
women’s needs. Some donors
were committed to building moreclinics, while others preferred tofund distribution schemes that
operated outside of health ministries’

STAT E OF WOR L D POPUL AT I ON 2 01 9

101

infrastructure, and still others funded
mainly research and demonstration
projects (Robinson and Ross, 2007).
Coordination was a particularchallenge in early population
programmes. Different national
institutions had responsibility for
different aspects of implementing
population policies: ministries ofhealth dealt with clinical service
delivery; central statistical offices
were responsible for censuses andsurveys; ministries of education
handled school and training
institution curricula; ministries
of information were responsible
for public education campaigns;
and ministries of planning or
finance allocated funds. In someplaces, population planning
units or national populationcommissions helped to coordinate
the multiple facets of population
policy, but often capacity to leadsuch efforts was low. The diffuse
administration of programmes
complicated delivery of the services
and information women needed toexercise their reproductive rights.
Another constraint in the earlydays of family planning programmes
was a paucity of data to guide theformulation of programmes ormonitor the impact of initiatives. In
the 1970s, the United States Agency
for International Development
helped to set up numerous central
statistics agencies, and sincethen, the scope and quality of
epidemiological and behaviouraldata on sexual and reproductive© Giacomo Pirozzi/Panos Pictureshealth from developing countries
have improved dramatically.
However, gaps remain in thecollection and analysis of data
for some events, outcomes andmorbidities, such as abortion,interpersonal violence, sexuallytransmitted infections, obstetricfistula, incontinence, pain withintercourse and sexual dysfunction.

FIGURE 7.1

Gradual progress

60

The reach of family planning
programmes expanded slowly in the
1970s and then more rapidly in thefollowing decades. In developing
regions in 1970, for example, anestimated 40 per cent of demand
for family planning was met with amodern method (Figure 7.1). That
percentage climbed to 57 per cent in
1980, 69 per cent in 1990, 75 percent by 2000, and is about 77 percent today (United Nations, 2018b).
This progress reflects a gradualexpansion in the “level of effort”
that governments put into theirfamily planning programmes. In
1972, researchers devised measuresof programme effort, and since thattime, have applied them periodicallyin most developing countries. The
Family Planning Program Effort
Index is based on a questionnairethat relates to 30 measures of levelof effort in four categories: policies,
services, evaluation and method
access. The effort index score isdrawn from questionnaire responses
from independent, informed
observers, and is assessed separatelyD emand for family planning met through modern
methods of contraception: percentage of women
who are married or in a union, 1970 to 2018

80

70

50

40

30
1970

1980

1990

from outcomes, such as contraceptive
use or fertility change.
When this index was first assessedfor 23 national programmes in
1972, countries were fairly evenly
distributed across a continuum from
low to high effort. By 1989, however,many countries’ effort scores had
climbed, with low-effort countries
beginning to resemble those in
middle- and high-effort categories(Robinson and Ross, 2007). This
progress in family planning effort,
however, is only one part of thepicture, and gradually, population
policies began to encompass morethan family planning.

2000

2010

2018

By 1976,
40 countries had
policies to lower
fertility; by 1986,
that number had
grown to 54, andby 1996, 82.

STAT E OF WOR L D POPUL AT I ON 2 01 9

103© Giacomo Pirozzi/Panos Pictures

Population policies:
moving beyond fertility
reduction
The groundbreaking consensus
achieved at the International
Conference on Population andDevelopment (ICPD) in 1994
helped to generate momentum
for the creation and renewal ofinstitutions. Over time, morenational population policies andstrategies broadened beyond theirnarrow focus on family planning forthe purposes of fertility reduction toencompass the new global agenda forsexual and reproductive health andwomen’s empowerment.

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CHAPTER 7

For example, as of 2015, 76 per centof governments had adopted one ormore policy measures in the previous
five years to reduce the number ofnewborn or maternal deaths, andmore than 70 per cent of governments
had expanded the coverage of essential
post-partum and newborn care, comprehensive prenatal care, or obstetriccare (United Nations, 2017a).
In addition, 62 per cent of governments around the world had adopted
a policy to expand recruitment andtraining of skilled birth attendants,
and 39 per cent had expanded accessto safe abortion care, including
post-abortion care (Figure 7.2).

In a global survey of progress in
implementing the recommendationsof the Programme of Action of
the ICPD, governments provided
information about the establishmentof various institutions “to address
issues related to the interaction
between population anddevelopment.” The findings suggested
that, compared with other themesof the ICPD, such as education andmigration, there was greater relative
growth in government institutions toaddress gender equality, adolescentsand youth, and population andsustainable development since the1990s (United Nations, 2014).

FIGURE 7.2

Percentage of governments having adopted policy measures in the past five years
to address newborn or maternal mortality, by region, 2015

Expanded coverage ofcomprehensive prenatal care

Expanded coverage ofobstetric care

Expanded coverage of essential
post-partum and newborn care

Expanded access to safe
abortion care, including
post-abortion care

Expanded recruitment
and training of skilled
birth attendants

Any of these measures

Expanded access toeffective contraception

World

AfricaAsia

EuropeLatin America andthe Caribbean

Northern America

Oceania

0

20

40

60

80

100

Percentage
Source: United Nations, 2017a.
Note: based on 190 countries with available data.

STAT E OF WOR L D POPUL AT I ON 2 01 9

105

These new institutions are mosteffective in advancing rights andchoices when they fully embrace theneeds and perspectives of potential
clients. The Programme of Action
emphasized the need to involve
those directly affected, particularly
people who were historically
excluded due to discrimination,
coercion or violence, in developing
laws, policies and practices. Suchinvolvement serves to empower
individuals, especially womenand girls, to more fully exercise
their rights.

The growing value ofpartnerships
Throughout the 1970s and 1980s,
partnerships within the realmof population and development
expanded, diversified andcontributed to much of thesuccess in advancing populationand development objectives(Weerakoon, 2002).
The Programme of Action
recognized this evolution, notingthat it was no longer unusual forgovernments and multilateralorganizations to work closelywith national and international
non-governmental organizations
and the private sector (United
Nations, 2014a).
The ambitious and expansive
goals of the Programme of Action
are in large part an outcome ofcivil society mobilization, and notsurprisingly, since 1994, a broad
range of civil society organizations

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and other non-governmental
stakeholders have increasingly
mobilized to shape global,
regional and national policy andaccountability frameworks on sexualand reproductive health (United
Nations, 2014). This trend hastaken place in the context of greater
diffusion of authority and leadershipin governance structures, and acorresponding recognition of thevalue that comes with participationand partnership among national andlocal governments, civil society, as
well as non-State actors.
Through the late 1980s andearly 1990s, a wave of government
decentralization initiatives offered
opportunities for civil society
participation in local planning,decision-making, and monitoringand evaluation of sexual and reproductive health services. However,decentralization also brought challenges related to lack of clarity in
how different institutions related
to each other and to district healthauthorities, as well as problems
related to commodity flows andprocurement and disbursal of equipment and supplies (Maceira, 2005).
With this evolution, theparticipation of intended
beneficiaries of the Programme of
Action has been enhanced over the
past 20 years, as wide networks ofcivil society and non-governmentalorganizations have been formallyrecognized and integrated inplanning and implementation(United Nations, 2014).

The Reproductive HealthSupplies Coalition, for example,
brings together civil society
organizations alongside multilateraland bilateral organizations, private
foundations, governments andprivate sector representatives
with the goal of ensuring thatall people in low- and middleincome countries can accessand use affordable, high-quality
contraceptives and otherreproductive health supplies. And
the Family Planning 2020 initiative
has engaged civil society in setting
strategies to achieve its goal ofproviding 120 million more womenand girls in the world’s poorest
countries with access to voluntaryfamily planning information,
contraceptives and services by 2020.
Similarly, the private sector hastaken on a larger role in programme
planning and implementation. The
Programme of Action recognized
the critical role the private, forprofit sector could play, andcalled on governments and nongovernmental organizations tointensify their cooperation withthe private sector in populationand development programmes,
particularly in such areas as the
production and delivery of highquality contraceptive commodities
and the delivery of services withappropriate information andeducation (United Nations, 2014a).
A worldwide field inquiry in 1998
found that the private sector inmany countries had begun to take a

CHAMPION OF CHANGE
She has been a doctor, a survivor of political
torture, a defence minister and one of theworld’s most notable woman politicians. Twice
elected President of Chile, Michelle Bachelet has
championed gender equality and sexual and reproductive rights, overseeing transformative changes inChilean legislation for women and girls.

Michelle Bachelet

Bachelet became the first ever woman President of Chile in 2006, quickly fulfilling a campaign promise
to have a cabinet comprising equal numbers of men and women ministers. She drew on long-standing
relationships with the Chilean women’s movement to bring feminists into the Government, who joined
ranks with her in advancing reforms on core issues of reproductive rights.
She successfully pushed to scale up protections for survivors of domestic violence, stop workplace
discrimination, make the pension system fairer to women, and improve childcare for low-income mothers.
When a conservative coalition stood in the way of her plan to expand access to emergency contraception,
Bachelet appealed to a supportive public and the bill was fast-tracked and approved. In 2017, towards theend of her second term as President, Bachelet propelled another landmark change as the Chilean Congress
ended a 28-year blanket ban on abortion.
“I was determined to carry out the kind of social, economic and political reforms that I believed werenecessary to make people’s lives better,” Bachelet says. “We had the courage to put Chile in motion, andwith it, we have seen Chile change.”
In 2018, Bachelet became the United Nations High Commissioner for Human Rights, vowing to draw on alifetime of experiences to promote human rights for all. “Those who defend human rights and the victims
look up to the High Commissioner and hope that we are there to
defend and support them,” Bachelet says. “And I’ll do everything on
my side to make sure that we do so.”
No more so than for women and girls. “Building a more equitable andjust world, that guarantees the rights of women and girls, is more thana challenge,” says Bachelet, who also served as UN Women’s first
Executive Director. “It’s a necessity and an obligation.”“I was determined to carry out
the kind of social, economic andpolitical reforms that I believed
were necessary to make people’s
lives better.”© UN Photo/Violaine Martin© UNFPA/Sanne De Wilde/NOOR

more active role in operating clinics
and initiating social marketing
programmes (Weerakoon, 2002).
With the growing diversityof partnerships and actors, theProgramme of Action called
on recipient governments tostrengthen national coordination
mechanisms to ensure efficient andeffective cooperation in populationand development. The Programmeof Action noted the need forclarification of responsibilities
assigned to development
partners, based on considerationof comparative advantages andnational development priorities,
and called on the international
community to assist recipient108

CHAPTER 7

governments in undertaking
these coordination efforts (United
Nations, 2014a). While retaining
their national priorities, donor
countries have supported increased
collaboration and harmonization
within the United Nations andwithin national processes as partof United Nations’ reform andthrough new network initiatives.

Challenges in estimating
and tracking funding
Estimating funding needs andtracking financial flows for sexualand reproductive health services
is a critical aspect of effectively
advancing the rights and choices ofpeople in need. Such efforts provide

information and transparency thatenable donors to coordinate efforts,
planners to identify priorities andgaps, and advocates to keep donors
and governments accountable totheir commitments.
But estimating and tracking financehas been a challenging exercise since
the earliest days of population
policies. In the 1960s and 1970s,
finance for sexual and reproductive
health fell into various budgetary
categories. Financing for maternaland child health and treatment
of sexually transmitted infections,for example, was categorized
within broader health funding,while “population” funding was
heavily concentrated on financing

CHAMPION OF CHANGE

Enkhjargal Davaasuren

Across Mongolia, people used
to avoid mention of the violence
that erupted within their homes.
In the communist era, the penalties were so severe that many women were reluctant to report evenserious crimes. In 1990, a democratic revolution took place, but in its wake, the court system stopped
recognizing domestic violence and marital rape as criminal offences.
For Enkhjargal Davaasuren, that was never acceptable. As a girl, her union activist mother held numerous
sessions at home where women organized for their rights at work, but also helped each other stop abuse.
Davaasuren went off to law school as another way to stand up for women’s rights.
As a young lawyer, she founded the National Centre Against
Violence and kickstarted a campaign to pass a new law
criminalizing domestic violence. For two decades, she and herteam of committed activists persistently called on politicians
to take action. It took until 2016, but their dedication paid off
when the Mongolian Parliament criminalized domestic violence
for the first time in the country’s history as a democracy. A newlaw ensures that the one in three Mongolian women who will
experience some form of domestic violence in their lifetimes
can seek safety and protection.
Davaasuren has faced death threats and criticism of“importing ideas from abroad” in her quest for change.
But she has never backed down. The National Centre
sponsors a team of lawyers to provide free legal
representation for survivors of abuse and establishedshelters across the country where women and girls canseek refuge and assistance. Awareness has spread, withmore women seeking assistance, and a palpable senseof public outrage has stirred through high-profile media
coverage of cases of abuse.
“We will never rest in our advocacy efforts,” Davaasuren
states. “In a male-dominated, patriarchal society such as
Mongolia, women don’t realize how strong they can be.”
She advises: “Be strong, but more importantly, becollectively strong. Women must work together toachieve social change. The challenges are systemic,
the solutions collective.”© UNFPA Mongolia“In a male-dominated,
patriarchal society suchas Mongolia, women
don’t realize how strong
they can be.”contraceptive services, with somedevoted to the collection andanalysis of demographic survey data.
In various studies, both health andpopulation expenditures were often
lumped together as “health sector”
funding, and historic data on
financing for specific interventions
are not easily parsed out.
Tracking efforts starting in the
1970s shed light on trends, andparticularly on the ways in which
the donor community ramped up

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CHAPTER 7

support for health and population
activities. Disbursements frommultilateral and bilateral agencies
for the health sector totalled nearly$900 million (in 1990 dollars) in
1972; this grew to $2.7 billion by1980 and $3.9 billion by 1990.
Of this, assistance for “population
activities” increased slowly during
the 1970s and 1980s. Total
population assistance grew to$936 million in 1990, almost
20 per cent of the total external

assistance for the health sector.
Bilateral donors accounted for
60 per cent of this population
assistance, United Nations agencies
for 22 per cent, the developmentbanks for 13 per cent, and private
sources for 5 per cent (Michaud
and Murray, 1994).
By 1994, systems for estimating
and tracking financing forsexual and reproductive healthservices had become much moresophisticated. The Programme ofGovernments agreed that two
thirds of the required amountwould be mobilized by developing
countries themselves, and one
third was to come from theinternational community.

Growing needs,
growing costs© Brian Sokol/Panos Pictures

Action itself included estimatedcosts for implementing core
recommendations in the areasof family planning; reproductive
health; treatment and preventionof sexually transmitted infections,
including HIV; and basic research.
The international community
agreed then to a “costed package,”estimating that $17 billion would
be needed in 2000, $18.5 billion
in 2005, $20.5 billion in 2010
and $21.7 billion in 2015.

A number of organizations andprogrammes have begun tracking
costs and donor assistance forreproductive, maternal, neonatal
and child health. For example, theFamily Planning 2020 initiative
tracks financing for family planning
globally; the Partnership for
Maternal, Newborn and Child
Health tracks financial commitments
to the Global Strategy for Women’sand Children’s Health; and the
Guttmacher Institute reports
funding and spending gaps for asuite of reproductive health services.
These estimating and tracking
mechanisms reveal progress andpersistent challenges in the financing
landscape since 1994. The numberof donors has steadily increased, anddonor efforts have increasingly been
shaped by the growing engagementof civil society and the private sector(United Nations, 2014).
However, globally, resources foraddressing sexual and reproductive
health needs remain insufficient,and donor trends are heading in thewrong direction. Disbursements ofofficial development assistance fromdeveloped to developing countries
for sexual and reproductive healthclimbed rapidly after the ICPD in
1994, and peaked in 2011 at justover $5 per woman of reproductive
age in the developing world. By
2016, however, this figure had
dropped by 60 cents per woman, to$4.40. When all sources of overseas
funding are considered, including
official development assistance andprivate grants, assistance for sexualand reproductive health amounted
to $6.22 per woman of reproductive
age in 2016. While significant, eventhese higher figures remain low whencompared with needs.

The central role ofdomestic finance
While difficult to measure, it
is clear that financial resourcesfrom developing countries as awhole, including funding fromgovernments, national nongovernmental organizations andprivate expenditures, accountfor the majority of funding that
supports population activities(UNFPA, 2014a).
Many developing country
governments have made progressin aligning domestic objectives
and budgets with Programme of
Action goals. But ongoing financial
crises in developing countries andcountries in transition can affectabilities to maintain momentum.
Further, opposition to population
programmes on religious and cultural
grounds has been an obstacle toresource mobilization in some places(Cohen and Abrams, 2002).

STAT E OF WOR L D POPUL AT I ON 2 01 9

111

Many countries, especiallythe least developed ones, are notable to generate the necessary
resources to fully meet the sexualand reproductive health needs oftheir citizens. Most developing
countries rely on donor assistanceto finance and maintain population
programmes (UNFPA, 2014a). This
challenges developing countries’
abilities to plan and budget oversustained time frames, since donor
funds can vary from year to year,
putting the stability of national
sexual and reproductive healthprogrammes at risk of sudden cuts.
Moreover, private consumers indeveloping countries take on a heavy
burden of sexual and reproductive
health costs through out-of-pocket
expenses. This has important
implications with regard to accessto critical services for the poorestand most marginalized populations.
In places where men control afamily’s discretionary income, forexample, women may face additional
challenges in paying for their own
sexual and reproductive healthneeds (Starrs and others, 2018). The
burden of out-of-pocket expenses canalso create challenges for initiatives
aimed at reducing poverty andincome inequality in the developingworld (United Nations, 2014).
Innovative financing approaches
are supporting and incentivizing
developing country governments toprioritize and sustain investments inunder-resourced areas such as healthand nutrition. The Global Financing

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Facility, for example, was launched in2015 and encourages governments
to increase domestic spending inalignment with health and nutrition
dimensions of the Sustainable
Development Goals (SDGs).
Similarly, the Bill & Melinda Gates
Foundation supports governmentsthat have committed to the Family
Planning 2020 goal of reducing theunmet need for family planning andare developing and implementing
country-specific plans to expand
family planning access.

Growing attention to aid
effectivenessThe launch of the Millennium
Development Goals (MDGs) in2000 ushered in an era of increased
attention to aid effectiveness,
prompted in part by frustrations ofdeveloping country governments
over problems of unequal aid
partnerships and the loss of theirability to effectively plan, coordinate
and lead the development process intheir own countries.
In the 2001 Abuja Declaration
on HIV/AIDS, Tuberculosis andOther Related Infectious Diseases,
Member States of the African
Union committed to increasing
health spending to at least
15 per cent of the national budget,and called upon donor countries
to scale up support accordingly.
The outcomes of the High Level
Forums on Aid Effectiveness(the Paris Declaration on Aid
Effectiveness of 2005, the Accra

Agenda for Action of 2008 and
the Busan Partnership for Effective
Development Cooperation of2011) strengthened commitments
to deliver aid more effectively,
with an emphasis on capacity
development and national
ownership and execution (United
Nations, 2014).
This growing attention to aid
effectiveness has been reflectedin the development of structures
for donor coordination, andgreater acknowledgementof country leadership andmutual accountability in thesecollaborations (United Nations,2014). A joint World HealthOrganization-UNFPA study ofthe implications of changes in theaid environment for sexual andreproductive health found a growing
focus on sector-wide approaches
and poverty reduction strategies, aswell as on strategizing to achieve
the MDGs. The study also foundthat secure, predictable funding
for sexual and reproductive healthremained a challenge (WHO andUNFPA, 2011).

Advancing universal
health coverageWith the advent of the SDGs in2015, increasing attention has been
focused on attaining universal healthcoverage, which is at the centre of
SDG 3. The concept of universal
health coverage embodies several
principles, including the provisionof high-quality services to improve

CHAMPION OF CHANGE
Heading up the population anddevelopment directorate in Cambodia’s
Ministry of Planning, Chea Chantum has
been instrumental in his country’s efforts
to put ICPD commitments at the core of progressive national policies on population, ageing
and a range of other issues.

Chea Chantum

Under his watch, Cambodia significantly scaled up investment in family planning. A country that only
a few decades ago was mired in conflict can now point to sharp declines in fertility rates, comparable
to those in much more advanced countries, as well as improved maternal health.
“We have stressed the right to have children but at the same time urged couples to think about
their own well-being and that of their family,” he says “So much can be done through education
and awareness.”
Cambodia is in the process of introducing comprehensive sexuality education as part of the national
curriculum from grades 5 to 12, building on the back of Chea’s persistent call to respect the sexualand reproductive rights of adolescents and youth. He also helped drive the creation of a national
health equity fund that provides free health care to poor citizens across the country.
A civil servant for almost 30 years, Chea started his career as a police officer before going on to get
degrees in rural development and public management. It was while spending time in rural areas that
he began to see the inextricable links between population and development.
“At first, I did not understand the importance of
population,” he recalls. “Now I know that populationis the main thing for development. That motivates
me to do everything I can to understand what people
need to improve their well-being.”“It is not enough just to provide a few services,”he stresses. “We have to include all people in ourdevelopment. If we don’t have people, we havenothing. Only people can make our country
continue to move forward.”“We have stressed the right to havechildren but at the same time urged
couples to think about their own
well-being and that of their family.”© General Secretariat for Population and Development,
Ministry of Planning, Cambodia

health and equity in access to healthservices without the risk of financial
hardship.
As embodied in the SDGs’
theme of “leaving no one
behind,” the concept of universal
health coverage also encourages“progressive realization,” theidea that prioritization should begiven to health-system reforms
that address inequities from theoutset, benefiting less advantaged
individuals to an equal or greater
degree than those who are moreadvantaged, and that every country

can make progress, regardless of
its starting point (Starrs andothers, 2018).
Universal health coverageenvisions a health service packagethat is successively expanded,
and increasing the share ofcosts that are covered throughpooled funding or insurance
schemes, so that out-of-pocket
expenses are reduced. The
concept also emphasizes the many
intersectoral links between theSDGs, recognizing that prospects
for achieving health goals will

be enhanced with progress inaddressing the multiple social andenvironmental determinants ofhealth (Stenberg and others, 2017).
Sexual and reproductive healthoutcomes have been improved
through various innovative
financing schemes such asvoucher programmes, conditional
cash transfers, social insurance
programmes and performancebased monitoring (USAID, 2014).
Such innovative interventions canbe effectively adapted for othersettings (Starrs and others, 2018).

© Mark Tuschman

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In support of these objectives,
multilateral institutions have cometogether to launch a collective
process to accelerate progress
towards the SDGs. The Global
Action Plan for Healthy Livesand Well-being for All aims toaccelerate impact in countries,
while reinforcing domestic
decision-making, promoting

rights-based, equitable responses
that leave no one behind, andenhancing learning among
countries and institutions.
Coordinated by the World HealthOrganization, the initiative unites
the work of 11 health-oriented
multilateral institutions. The groupwill finalize the action plan to bedelivered in September 2019 at theUnited Nations General Assembly(WHO, 2018a).
Together, these initiatives are
setting the stage for institutions
that are better equipped andsustainably funded to expand
access to information andhigh-quality services thatcan enable women to exercise
their reproductive rights.

CHAPTER HIGHLIGHTS•Over time, the policies and programmes ofgovernments and other sexual and reproductive
health service providers have evolved in
response to growing understanding of sexualand reproductive health. Institutions need tocontinuously adapt to be able to meet thegrowing needs for a broader range of sexualand reproductive health services and to extend
rights and choices to all people everywhere.

•

The participation of national and local
governments, civil society and the private
sector has helped to shape the ambitious
goals of the International Conference on
Population and Development (ICPD) andthe Sustainable Development Goals (SDGs);
partnerships among these actors have been
central to progress towards these goals, andwill be critical in their achievement.

•

Estimating funding needs and tracking financial
flows for sexual and reproductive health services
is a critical aspect of advancing the rights andchoices of people in need. Globally, resources
for addressing sexual and reproductive healthremain insufficient, and donor trends are headingin the wrong direction. Many developing country
governments have made progress in aligningdomestic objectives and budgets with ICPD
Programme of Action goals, but ongoing financial
crises affect abilities to maintain this momentum.

•

Attaining universal health coverage is at thecentre of SDG 3. Such coverage includes theprovision of high-quality services to improvehealth and equity in access to health services
without the risk of financial hardship. The adventof initiatives to promote universal health coverage
offers opportunities to advance institutions thatare better equipped and sustainably funded to
expand access to information and high-quality
services that enable rights and choices for all.

STAT E OF WOR L D POPUL AT I ON 2 01 9115

© Laxmi-Prasad-Ngakhusi

CHAPTER 8

REALIZING RIGHTSAND CHOICES FOR ALL:IF NOT NOW, WHEN?
A woman who is 60 years old was born when sexual andreproductive rights and choices were more constrained. It was
hard for many to obtain contraception, and relatively easy todie giving birth. But by the time she was 10, change had begun,
producing steady gains.
Some changes benefited her, butmany more accrued to the next
generation, the women who were 10
when the International Conference
on Population and Development(ICPD) took place. Yet even forthem, progress today is incomplete.
Now aged 35, they have more rights
and more choices, but not all thathave been promised.
Can we do better for a girl who is
10 today? If history is a guide, theanswer is yes, if we put people firstand leave no one behind.
Many remarkable advances in
expanding sexual and reproductive

health and rights have beenchampioned by governments,
civil society and internationalorganizations over the past 50
years. In 1994, the ICPD offereda visionary global commitment
to these rights and choices, andan unprecedented consensus on
the essential ties between women’s
empowerment and development.
Twenty-five years later, the ICPD
vision remains a high point of humanaspiration, reflected now acrossthe 2030 Agenda for Sustainable
Development and its 17 Sustainable
Development Goals (SDGs).

Looking forward, however, someold problems remain. And newones have emerged. As a measureof the task ahead, UNFPA andits many partners have issued aclarion call for three zeros by 2030:
there should be no unmet needfor contraception, no preventablematernal deaths, and no violenceor harmful practices against
women and girls.
A girl who is 10 today deservesa world where everyone enjoys
all of their rights and can live thelives they choose.

STAT E OF WOR L D POPUL AT I ON 2 01 9

117and climate change undercut
advances and impede rights andchoices. Shrinking populations insome countries have opened thedoor to new forms of population
policies aimed at pushing people
to have children, while in otherplaces, fears about population
growth have re-emerged. Other
demographic shifts such as
migration, in many cases reflecting
deep-seated inequalities and crises,
have fanned intolerance. Poverty
remains profound and intractableeven in many countries that as awhole are better off. Conservatism
and fundamentalism could block
progress and reverse what has been
attained.
Putting people first© UNFPA/R. Anis

A transformative vision:from the past, for the
futureIn the late 1960s, population
growth was feared, conceived asa ticking time bomb to urgently
defuse through aggressive, attimes coercive, family planning
programmes. By the time of the
ICPD, consensus had emergedthat people have a right to control
their bodies and their sexual andreproductive lives. When theyrealize this right, they often makechoices that benefit themselves, and118

CHAPTER 8

support broader social, economicand even environmental well-being.
Today, the 2030 Agenda recognizes
that sustainable development
hinges on universal quality healthservices, including sexual andreproductive health care, as wellas the achievement of genderequality and the realization of
reproductive rights.
Gains are fragile in an often
unstable and troubled world,
however. Some people are surging
ahead, but many are left very
far behind. Epidemics, conflict

For all countries, making the mostof existing gains, overcoming
obstacles and embracing abetter future, including theone envisioned in the 2030
Agenda, starts with acting on
the commitments of the ICPD.
These include putting people firstby upholding their sexual andreproductive health and rights aswell as the right to development
for both current and future
generations.
National legal systems canmake explicit commitments tothese rights, and shed remaining
discriminatory provisions, suchas barriers to access services andcontraception for young people,
unmarried people, migrants,

people of diverse sexual orientationand gender identity, and others.
These commitments can then betranslated into practice throughwell-designed population anddevelopment policies that prioritize
reaching people who have thefewest choices and face the greatest
shortfalls in realizing their rights.
Recognizing the complex
interactions between sustainable
development and population
dynamics, population issues should
also cut across broader development plans and investments, andbe part of the integrated approachto development now embodied by
the 2030 Agenda. These efforts
should reflect the full range offactors that influence sexual andreproductive health and rights,
including education, work,
housing and food security.
Countries concerned about
shrinking populations can act toensure that essential sexual andreproductive health services arereadily available to all. They may
also need to do more to advancethe reach of family-friendly policies
to help people exercise their rights
to start or expand a family, suchas paid parental leave for men andwomen, tax breaks for families,
flexible work arrangements andaffordable housing. Countries witha greater share of people entering
the workforce can boost productivity and make more of potential
demographic dividends by ensuringthat younger people can accessquality, comprehensive essential
health services as well as quality
education, and have opportunities
to move into decent work.
Within national health policies,
sexual and reproductive healthshould move from an often
peripheral role to a central one,matching its impact on overall
health and well-being and theimportance individuals andcouples give it. This could include© UNFPA/Live Images

guiding a move towards the recent
Astana Declaration definition ofprimary health care as integrating
preventative, curative, sexual andreproductive, and mental healthservices (WHO and UNICEF,
2018). National sexual andreproductive rights “check-ups”
could assess whether laws, policies,
budgets, services, awarenesscampaigns and other activities
are aligned with these rights.

Rights and choices acrossthe life cycle

Significant shifts in population
patterns in recent years, particularly
across different age groups, have
led to greater appreciation of thevalue of taking a life cycle approachin planning and policymaking.
Public services and otherinterventions should reach people
at the start of life and continue
to be available at each subsequent
stage, building on each otherthrough old age.
This helps countries realize rights
for people at all stages of life andmaximize high-impact investments.
Children and young people will
have the health and education theyneed to become capable working
adults. Adults will have the decent© Chien-Chi Chang/Magnum Photos

work and family planning support
needed to productively contributeto the economy, care for theirdependants and prepare for older
age. Older people can draw on
accumulated resources and sustain
their quality of life, and continue
contributing to their families andcommunities. A life cycle approach
can help reduce age-related
inequalities, and guide choices
about resource consumption tobalance the needs of current andfuture generations.
Social protection systems witha minimum safety net of benefits
should be available to people at allstages of life, ensuring that people
can maintain a level of dignity,
choice and well-being in line with
their rights. Employment policies

need to keep up with rapid shifts
in labour markets that undercut
job stability and quality, such as
through a continuum of essential
health and social security benefits,
and commitments to lifelong
learning.

An unfinished agenda:
access to quality services
Over 50 years, understandingof the nature of sexual andreproductive health services has
steadily evolved. A near-exclusive
focus on contraception widened to
the ICPD call for universal accessto a full range of services related tosexual and reproductive health care.
Universal health coverage is now
a major emphasis of SDG 3 onhealth and well-being for all.

A universal package ofservices

The highest unmet needs for sexualand reproductive health services
are among marginalized groups,
including minority ethnic groups;
young people; unmarried people;
lesbian, gay, bisexual, transgenderand intersex (LGBTI) people;
people with disabilities; and therural and urban poor. Among
poorer women, not only is theunmet need for contraception
more pronounced, but maternalmortality rates are markedly higher.
Low-quality care, insufficientfacilities and supplies, discriminatory laws and dismissive treatment
by service providers are among thebarriers still preventing womenand girls from accessing services.
Reaching and fully realizing therights of long-excluded groups
can be difficult and expensive,
but must be a central priority
in finishing the ICPD agenda
and achieving the 2030 Agenda.
Services not only need to physically reach these groups, but also be
tailored to the needs they express,
confidential, and free of judgement
or coercion.
All health systems should
define and deliver an essential
package of universally available,
integrated, high-quality sexual andreproductive health care services,at primary and referral levels. The
ICPD defines these as comprisingfamily planning; services related
to pregnancy, sexually transmitted

infections, infertility and safe
abortion where legal; and referrals
for reproductive system cancers. In
general, integrated services do more
to respond to multiple needs, suchas when contraceptive counsellingis provided before and after birth.
Weak maternal and child healthprogrammes need to improve,
supported by related programmes
in nutrition, food security andwomen’s empowerment. Througha Maternal Health ThematicFund, for example, UNFPA helps
countries with particularly highburdens of maternal mortality
through proven interventions suchas training for midwives and theinclusion of comprehensive sexualand reproductive health care in
emergency obstetric and newborncare facilities.
There is also a need for moreconcerted efforts to end taboos
and misinformation aroundmenstruation and strengthen
facilities and services for managing
menstrual hygiene, given
consequences that range frominterrupted education to untreatedhealth problems.
Many countries can do much
more to uphold rights and choices
for all by removing barriers toservices and information for people
with diverse sexual and genderorientations. Dismantling these
could start with training andsensitizing health-care workers to
avoid discrimination and meet
special needs.

Making links to end violence

Major gaps remain in preventing
and responding to gender-based
violence, a globally pervasive
violation of rights. Shelter systems,
despite dedicated efforts by
women’s organizations, are still
marginal or non-existent in many
places. Integrated service models
can be introduced or scaled up
to help women readily access the
combination of health, judicial,
psychosocial, employment andother forms of support required
to find safety and restart theirlives. Successful experiences intraining police units and judicial
officials to respond to the special
circumstances around gender-based
violence could be more widely
shared and replicated.
Stronger links could be forged
between reproductive healthservices, initiatives to preventand protect against genderbased violence and economic
empowerment programmes for
women. These links could be as
basic as screening and referral
systems, so that women seeking
family planning services, forexample, are asked about otherneeds and risks, and referred as
appropriate to additional resources.
Accountability starts withservice users

One major reason for deficits
in service quality, beyond low
resource levels, relates to the lack of
accountability and responsiveness

STAT E OF WOR L D POPUL AT I ON 2 01 9

121© Thomas Imo/Photothek/Getty Images

to service users. Stronger healthinformation management systems,
as well as efforts to systematicallyrecord and analyse all maternal
deaths to identify shortfalls in
care, would empower countries
to monitor progress and confirm
that services are reaching thefurthest behind first. A positive
trend has been the adoption ofminimum standards and complaint
procedures. Where health care is
being privatized, regulations shouldreflect these standards and require
private providers to respect thesexual and reproductive healthand rights of all users.
Involving women’s groups andother representatives of service

122

CHAPTER 8

users in policy and service decisions
can also go far in improving thequality of care. Systems that could
be further developed include thosethat send a simple follow-up survey
to mobile phones asking service
users to weigh in directly on thequality of care. The results could
be used to assess the performanceof care providers. This kind of
approach can both improve services
and encourage their use.
Including adolescents

Adolescents as a group haveconsistently lacked access to sexualand reproductive health services,
despite ICPD commitments todeliver them. Legal norms andlong-standing norms still stand in
the way. New issues have emerged
from the Internet, which offers aflood of information, correct orotherwise, along with risks such as
cyberbullying and sex trafficking.
Adolescents have the right to be
educated and empowered to makechoices and protect themselves.
This right can be supported bymeasures such as age-appropriatecomprehensive sexuality education,
integrated in school curricula andreaching all students, and capable ofreaching girls and boys who are notin school. Such programmes should
provide information, but to achieve
the most significant outcomes,
should also aim to improveself-esteem, build understanding of
human rights and positive gendernorms, and develop decisionmaking and communication skills(Starrs and others, 2018).

addressing infertility, and insome countries to reform laws on
infertility treatment, adoption andsurrogacy in line with sexual andreproductive rights.

Facing fertility challenges

A growing reproductive
cancer burden

As many as 180 million couples
worldwide are potentially affectedby infertility, with consequencesthat can include psychologicaldistress, intimate partner violenceand social stigma (Starrs andothers, 2018). Important driversof infertility include the shifts inwork and family that have drivena growing number of women
to postpone childbearing until
later ages when they may facefertility challenges. Ill health andlack of access to care during firstpregnancies can also result in
the inability to have additionalchildren.
For those with resources, assisted
reproductive technology such as
in vitro fertilization is available.
Given the universal characterof reproductive rights and theprinciple of universal health care,however, such options need to bedelinked from the ability to pay.
Expanding access requires having
appropriate ethical guidelines
and medical standards in place,reducing prohibitive costs, andbroadening capacities to obtain
technology across countries atdiverse stages of development.
More could also be done to raiseawareness about preventing and

In all countries, cancer burdens
are expanding, with a particularly
pronounced jump in low- andmiddle-income countries as people
live longer. Other risks relate tolower levels of physical activity
from modern jobs. Prostate,breast, cervical and other formsof reproductive cancer constitutea significant share of the cancer
burden (American Cancer Society,2016). Routine screening should
be expanded as integral to primary
medical care, including throughestablished techniques and the
exploration of new ones suchas genetic testing, which are
beginning to decline in cost. Inline with a rights-based approach,part of accelerating access may
include reviewing intellectual
property processes and hastening
the speed with which technology
meeting a public good moves fromdevelopment to broad use.
One demonstrated tool for
prevention is the vaccine forthe human papillomavirus or
HPV, which causes most casesof cervical cancer. It is now
routinely administered to girls
aged 9–13 in 55 countries. Other
countries should consider moving

towards adoption, particularly
with a new dosing schedule thathas reduced cost.
Factoring in ageing

The ICPD pointed to the factthat the distinct reproductive
and sexual health issues of older
women and men are often
inadequately addressed. With
growing numbers of older people
in more and more countries,
health systems will need to take up
issues around sexual functioning,risks around HIV and sexuallytransmitted infections, andreproductive cancer risks thatrise with age.
More attention to mental
healthDespite the stipulation in the
ICPD that “everyone has the rightto the enjoyment of the highest
attainable standard of physical andmental health,” the latter remains
a poor cousin to the former inattention and resources. Yet mental
health issues can have a significant
impact on rights and choices.
Ante- and postnatal depression
remain common problems
worldwide, for example.
Unintended pregnancies arelinked to longer-term depressive
episodes. Continuing unmet
need for family planning, side
effects of contraceptive use, andpower imbalances in relationships,
including violent responses tounintended pregnancies, are

STAT E OF WOR L D POPUL AT I ON 2 01 9123

among the factors posing mental
health risks to women and girls.
Suicide is now a major cause ofdeath for adolescent women.
At a minimum, reproductive
health services should haveproviders trained on these issues,and screening and referral processes
in place to detect and respondto them (WHO, 2009). These
efforts should operate with respectfor human rights, and dignity,and make efforts to reduce thepronounced stigma that often
remains around mental health.

Fundamentals:
empowerment
and equality
The ICPD drew historic attention
to women’s fundamental right tomake choices about their bodies.
This is a right that underpins
many others—to learn, to work, tomove freely in public and private
spaces, to enjoy free time. Since
1994, in every part of the world,
women and girls have streamed
into education and the workforce.
On balance, they are healthierand better equipped to plan
their families.
Still, women are paid less, domore than their fair share of
unpaid care work, and have yet
to crack parity in most decisionmaking positions, from corporateboards to parliaments. Genderbased violence goes unpunished;harmful traditions result in the
mutilation and marriage of girls.

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Challenging gender norms

Discriminatory gender norms
remain among the most significant
drags on progress for womenand girls, appearing in every areaof life. They dictate a secondclass status, impeding rights andlimiting choices. High-quality
comprehensive sexual andreproductive health informationand services must be extended
to all women. But actual accessand use may also depend on ahusband’s willingness to let his
wife leave the house, the messages
sent by mass media, community
standards around sex and fertility,or the words of religious or otherfigures of authority. Empowerment
is often used as a blanket term
to indicate that women have theright to choose, but in reality
there are many factors related toa woman’s own means, her status
in her household, and the broadersocial, economic and politicalenvironment that reduce theoptions she can choose from.
Sexual and reproductive
health services should become
more effective in responding to
the realities of gender roles andnorms. Many remain top-down
providers. A mode of respectful
engagement, grounded in twoway communication and free ofjudgement, would help individuals
think through and define theirsexual and reproductive healthgoals, and understand how they
can achieve them. Service providers

should be trained to avoid
gender-discriminatory norms andbehaviours, many of which still go
unquestioned. They could learn to
ask about and assist with, directlyor through referrals, discriminatory
barriers that might arise once awoman leaves a health facility.
Broader social awareness andbehaviour change campaigns
can support shifts towards morepositive, broadly accepted norms.
Measures are still needed to end
gender stereotyping in schools,
including those that track girls
and boys into some forms of study
over others. Work with the media
should aim at reducing often
rampant gender stereotyping, andraising the still limited visibility ofwomen’s voices and perspectives.
Successful experiences in working
with religious leaders, who canhave a profound influence incommunities and households,
should be better understoodand replicated.
Ending all harmful practices

Some of the most insidious gendernorms result in harmful practices
such as child and forced marriage,
female genital mutilation andson preference. These need to
be entirely eliminated, startingwith clear legal statutes backed by
implementation. Some progresshas been made in working withincommunities to explain theharm that these practices impose
and build consensus aroundCHAMPION OF CHANGE
The 2017 imposition of a United States policy
restricting funding for reproductive health services
did nothing to silence Lilianne Ploumen. In fact, it
inspired her to speak out. The parliamentarian andthen Dutch Minister of Foreign Trade and Development Cooperation called on women around the world
to send their own message: no one decides about women’s bodies except women themselves.

Lilianne Ploumen

The SheDecides movement was born. First there was a hashtag, and then a pledging conference thatraised $200 million from governments, foundations and philanthropists. A crowdfunding platform wascreated. Over 50,000 people have signed a manifesto committing themselves to ensuring that “shedecides,” while national ministers in France and South Africa are among 40 prominent champions
dedicated to spurring momentum.
“Brave, tireless and brilliant organizations and individuals have been working on matters concerning girls’
and women’s bodily autonomy and comprehensive health care for decades. And suddenly, the rest of theworld was paying attention,” Ploumen says. “[We are] embracing a new energy and a new language thatbrings more and more people, from all walks of life, on board to embrace the idea of SheDecides.”All told, Ploumen estimates that at least $600 million a year will have to be raised to make up for
losses imposed by the so-called gag rule, a policy decision in the United States to shut off funding fororganizations that, with their own funds, provide abortion counselling or referrals, or that advocate to
decriminalize abortion or expand abortion services, even where legal.
A former community outreach worker in Rotterdam, Ploumen led
Mama Cash, a fund for advancing women’s rights, and managed
the international programmes at Cordaid, a major providerof relief and development assistance. She has seen first-handthe mix of norms, values, laws, codes and habits that prevent
women from being who they can be—everywhere in the world.
“These written and unwritten rules have to change,” she says.
“And here is where I ask everyone to stand up and make yourvoice heard, be in solidarity, call on your governments andorganize for change!”“[We are] embracing a new energy
and a new language that brings
more and more people, from allwalks of life, on board.”© Lex Draijer from Flickr

abandonment, including througha joint programme of UNFPAand the United Nations Children’s
Fund in a number of countries
with high rates of female genital
mutilation (UNFPA and UNICEF,
2018).
Proactive championing of therights and potential of girls could
shift tendencies to treat them
primarily as a burden or sourceof household labour. Where girls
can remain in school, including
through measures such as targetedcash transfer schemes, andeventually move into decent work,
they realize their rights, and parents
and communities begin to see
their capabilities and promise.
Engaging men

Most reproductive healthprogrammes have focused heavily
on women and girls, for thejustifiable reason that reproduction
takes place in their bodies, and they
are still significantly behind men
and boys in exercising rights andchoices. Yet men and boys must be
better engaged, both to enlist themin advancing gender equality andto respond to their rights andspecific needs.
A growing number of interventions support men as active agentsin reproductive processes. These
include couples’ counselling tofoster communication and resolve
conflict, and comprehensive sexuality education that stresses women’s
empowerment and men’s roles and126

CHAPTER 8

obligations. Other initiatives haveworked with groups of men to
redefine harmful masculine norms,
and broken down patterns contributing to gender-based violence.
Parental leave for men brings theminto childcaring from the beginning, and should be more widely
available. The many benefits ofmale involvement before and after
delivery include reduced odds ofantenatal and post-partum depression, and improved use of postnatal
care (Starrs and others, 2018).
Sexual and reproductive healthprogrammes in many instancesneed to explicitly reach out tomen as clients, including in familyplanning and the prevention ofsexually transmitted infections.
Investment should increase inmale contraceptive methods
as well as services responding
to issues such as male sexual
dysfunction and reproductive
cancers. Specific forms of outreachand counselling may need to
be developed in contexts where
men avoid seeking health carefor reasons such as the fear of
appearing weak, or because they
think that clinics are mainly for
women and children.
Equalizing up

For far too many women,
economies are failing to deliver,in ways that compromise
their sexual and reproductive
rights and choices. They holda disproportionate share ofpoorly paid, insecure jobs, forexample, and have less access tosocial protection. New models
of inclusive growth should be
gender-equitable and emphasize“equalizing up,” including
through eliminating gender gaps
in unemployment and increasing
decent work for both women andmen, but with a higher rate of
expansion for women (Elson and
Fontana, 2019).
Everywhere in the world, evenin countries that have moved a© Pep Bonet/NOOR

significant way towards genderequality, women carry a greater
burden of unpaid care work that
unfairly diminishes time for paid
work and leisure. Globally, womencomprise 40 per cent of the formal
workforce, but do between 2 and10 times more caregiving anddomestic work than men (Starrs
and others, 2018). For many
women, having a child still requires
leaving the workforce, remaining
outside it longer than they would
like, or simply struggling to keep

up. Some pay steep costs in termsof income and health.
Affordable housing, clean
energy, safe public transport, cleanwater and sanitation, and health,education and childcare services
can all reduce women’s unpaid
work (Starrs and others, 2018).
Much better evidence is needed inmeasuring time use as the basis fordefining investments in services
and infrastructure that contributeto gender equality and reach thefurthest behind first. Costing

exercises could define the extent towhich services and infrastructure
weigh on the public purse, anddeliver returns such as throughproductive employment andhigher tax revenues (UN Women,2018). Another element entails
encouraging men to do theirfair share.
Beyond the imperative of
realizing women’s rights, a growing
number of countries have started
to realize that “equalizing up” candeliver an extra momentum to

STAT E OF WOR L D POPUL AT I ON 2 01 9

127© Holly Pickett/Redux Picturesdemographic transition, yielding
a women’s demographic dividend.
Well-educated, healthy women
who realize their reproductive
rights and choices can make asignificant contribution to a
productive, thriving economy.

Continuity in timesof crisis
From intractable conflicts toclimate-related disasters, today’s
world is prone to crises that
regularly constrain rights andchoices. The ICPD called forprotecting people forced tomove or in vulnerable situations,
including through sexual andreproductive health services.
Crisis must not put rights andchoices on hold. Yet financial
support has consistently lagged
behind acute needs. For a pregnant

128

CHAPTER 8

woman fleeing catastrophe, skilled
medical care can be as essential
to her life and that of her child as
food and shelter.
Reproductive rights and choices
must become integral to allinternational responses to crisis.
All humanitarian actors, public
or private, from governments
or non-governmental groups,
should apply the minimum
standards for services to stop andrespond to sexual violence, reduce
HIV transmission, and prevent
maternal and newborn death andillness. Comprehensive sexual andreproductive health care should
be provided as soon as conditions
allow.
Pursuing opportunities

Crises, while never wanted, canopen opportunities to improverights and choices. More could bemade of these, such as throughprogrammes that may be the firstchance people have to learn about
sexual and reproductive health,challenge gender norms or seek
refuge from gender-based violence.
Amid the disruption, women andgirls may explore new roles, such as
through job training. More could
be done to boost investment inpsychosocial services and mental
health, since gaps can quickly
lead to risky sexual and otherbehaviours, ill health and genderbased violence, among otherconsequences.
Being preparedNot all crises can be avoided.
Being prepared means putting inplace plans to manage disasters
and mitigate risks. Where supplies

CHAMPION OF CHANGE

Sheshkala Pandey

Sheshkala Pandey was supposed to get married ineighth grade. But instead, the 19-year-old is today
attending college, mentoring other girls, and recently
received a national honour, the Unsung Hero Award.

Such developments could not have been readily predicted when Pandey was born. In her impoverishedcommunity in southern Nepal, girls have traditionally been married off as young as possible, despite alegal minimum age of 18. With no chance to finish their education, for many, marriage is the entry point
to a lifetime of continued poverty and disempowerment.
Pandey was determined that this would not be her fate. When the subject of marriage first came up in her
family, she burst into tears. Then she created a business plan, borrowed money from her brother and set
up a small business making handicrafts to sell in a local market. She earned enough to manage her school
tuition fees, a cost that often pressures family finances enough for parents to withdraw girls
from school and push them towards marriage.
For Pandey, change in her own life was only a starting point.
Today, when she is not studying for her university degree,
she teaches in a local boarding school to support herself.
She also heads a 30-member Girls’ Circle, which mobilizes
against harmful practices such as child marriage andsexual abuse and calls for girls to stay in school. When
members hear that a child marriage is about to takeplace, they intervene to stop it, even in one caseinterrupting a wedding ceremony.
“I encourage [girls] to be bold to withstandall sorts of untoward violence against them,”
Pandey says, adding matter-of-factly: “We haveto change the society, so why get disturbed by
obstacles on our way?”
Pandey’s courage in showing the way forward has
meant that more girls in her community are now
staying in school. Mothers come to ask her how
their own daughters can become like her. She
is the harbinger of a new norm, one where agirl should be treasured and encouraged, notdiscarded through child marriage.

© UNFPA Nepal/S. Chhetri“We have to change
the society, so why get
disturbed by obstacles
on our way?”are pre-positioned to respond todisasters, they should by default
include contraceptives, safedelivery kits and other essentials
for reproductive health. Integrated
service models can anticipate
personnel and measures required
to maintain continuity. All ofthese efforts should be backed byexpanded disaster risk financing,which is often inadequate. One
promising practice is to convene
national risk boards that develop
guidance from the pooled expertiseof insurance supervisors, disastermanagement agencies and relevant
ministries, including those working
on health and gender equality.
© Jonas Bendiksen/Magnum Photos

Building resilience

Some of the best disaster-proofing
comes when people are resilientand have means to protect
themselves. Strong health-caresystems with a full array of sexualand reproductive health services
can reduce vulnerability andimprove the choices people are
equipped to make. Universally
accessible social protection
programmes can sustain health,education and income, three pillarsof resilience for people on themargins. They can determine if
and how well people survivea crisis, inform choices about
whether to stay or flee, and support

eventual transition away fromexternal humanitarian assistance.

Accelerate action tocomplete the ICPD
agendaTo finish the unfinished business of
the ICPD and to move realisticallytowards realizing the 2030 Agenda
and the SDGs as well as thethree zeros—no unmet need forcontraception, no preventablematernal deaths, and no violenceor harmful practices against womenand girls—most countries canbuild on the foundation of recent
achievements. Many countries now
have basic institutions and policies

in place related to population
and reproductive health, butneed to reach those furthest
behind, improve service quality
and respond to emerging shifts indemographics and development.
They will need to plan strategically,
based on correct evidence, which isstill often lacking, and appropriate
investments, which have grown but
remain insufficient.
Getting the right institutions

Realizing rights and choices will
not be achieved by working issue
by issue. Health systems as awhole need to be strengthened
to offer people the full arrayof essential services they needover a lifetime. A recent study
published by The Lancet estimatedcosts for most countries to meetthe health targets of the SDGs,
predicting that about threequarters of additional investments
would need to go towards healthsystems’ strengthening, such as
for expanded health workforces
and facilities (Stenberg and others,2017). In many developing
countries, despite moves towards
decentralizing health and otherpublic systems, significant work
remains in improving subnational
capacities, ensuring adequate
financing and responding flexibly
to needs that vary across locations.
Recognizing the integrated
nature of the SDGs, a national
vision for universal health coverage
would draw strong links to thediverse determinants of health, andsexual and reproductive health inparticular. These include a clean
environment, which supports
health during pregnancy and may
reduce reproductive cancer risks.
Decent work helps women plan
their families by offering higher
levels of income and autonomy.
Education equips young people
to make informed and healthy
choices. As is already the casein some countries, national
mechanisms that bring together
people working in different arenas
can develop deeper understandingof how different issues interact andbuild on each other.
Since the ICPD, greater
accountability for rights andchoices has emerged through thewide involvement of civil society
and non-governmental groups
in policy and planning. Many
have been supported by UNFPA.
Engagement continues to evolve,
such as through the Reproductive
Health Supplies Coalition andFamily Planning 2020. Amongother challenges, these groups
could draw attention to the sexualand reproductive health services
that do not feature in the SDG
targets and indicators, given therisk that these will rank low ingovernment policy and investment
choices.
In some cases, expanded
networking and capacity-building
may be a priority to involve a
broader cross section of civilsociety and non-governmentalgroups, not just those witha national or internationalpresence, but those from smaller
communities and marginalizedgroups. The participation of youth,
the elderly, LGBTI people, people
with disabilities, and indigenous
and other minority communities
could advance in many cases.
There should be attention tomultiple levels of diversity, suchas young women from poor
backgrounds.
Other forms of accountability
might come through thedeliberate inclusion of sexual andreproductive health and rights inthe oversight responsibilities ofnational human rights institutions
and through parliamentary reviews.
Judicial system capacities could
be further developed to reduce
discriminatory legal practices,which persist even when laws
are aligned with human rights
standards.
Finding the money

Tracking financing for ICPD
commitments has provenchallenging, albeit with strong
indications that funding remains
insufficient. The ICPD stipulated
that two thirds of the required
amount would be mobilized bydeveloping countries themselves,and one third from theinternational community.
In terms of funding priorities,
publicly funded health services

STAT E OF WOR L D POPUL AT I ON 2 01 9

131

CHAMPION OF CHANGE
Dany Stolbunov, now 20, admired and trusted his
doctor in Ukraine enough to confide in him that
he wanted to go to medical school. He hoped
for affirmation of his dreams. Instead, he met
rejection. “You can’t be a doctor,” his doctor said. “You have HIV.”

Dany Stolbunov

Born with HIV, Stolbunov learned he had the virus at age 8, when his father died of AIDS. As hegrew up, he saw first-hand the stigma that still persists around HIV and AIDS even among people
in health-care systems who are supposed to be on the front lines of treatment. As a young adult,
he became determined to advocate for less discriminatory care.
“We are the first generation born with HIV who are growing up and can openly speak about it,”he told people attending the 2018 International AIDS Conference, the largest global gathering ona health-care concern.
As a leader of the Ukrainian organization Teenergizer!, Stolbunov performed at the conference in adocumentary theatre production, “Don’t Tell Anyone.” It showcases what it means to live with HIV
in Eastern Europe and calls for listening to the voices of young people living with HIV.
Created by adolescents for adolescents, Teenergizer! advocates for every teenager to realize theirfull potential and rights, and for ending all forms of discrimination, including those against people
living with HIV. Young people are still not seen as a priority in accessing even basic information
about HIV, even though globally, HIV is a leading cause of death among people aged 10–19.
Stolbunov also co-chairs The Pact, a coalition of more than
80 youth-led organizations and networks committing toadvancing sexual and reproductive health and rights, andending AIDS by 2030. He proclaims: “Nothing for us,
without us. We are ready to fight for our rights.”“Nothing for us, without us.
We are ready to fight for
our rights.”© UNICEF/Vlasova

generally offer maternal, newborn
and child health care as well asfamily planning, albeit to a lesser
degree. HIV/AIDS services havereceived significant donor financein endemic areas, while far fewer
domestic or international funds havegone towards services to address,for example, infertility, reproductive
cancers and sexual violence (Starrs
and others, 2018). Evening out
distribution would be an importantelement in rolling out a universal
package of essential sexual andreproductive health services.
One study estimated that formost countries to meet all thehealth targets of the SDGs, up to$371 billion is needed per yearby 2030, rising from an initial$134 billion per year (Stenberg
and others, 2017). Among otheroutcomes, this would cut maternalmortality nearly in half, avert 400
million unplanned births, andprevent 10.8 million deaths from
HIV/AIDS.
Middle-income countries arewell equipped to self-finance theinvestment required and evenbe more ambitious, the study
concluded. Low-income countries
will face a financing gap and willcontinue to need external financial
support, but even the poorest can
aim for some level of universal
health coverage. All countries willneed to prioritize investments inline with the principle of equity andreaching the furthest behind first,
and according to commitments

to human rights. Developing
countries that have successfully
financed expanded services havetaken measures including using
tax revenues to subsidize target
populations, increasing enrolment
in government health insurance,and decreasing out-of-pocket
spending by households whileboosting the government’s shareof total health expenditures (Starrs
and others, 2018).
A rights-based approach tobudgeting can guide choices
and may define new priorities,
such as increasing allocations foruniversal access to a full arrayof contraceptives in the poorest
communities, and adjusting tax
policy in a progressive fashion to
generate revenue to expand services.

Currently, 100 million people ayear fall into poverty because of healthcosts (Starrs and others, 2018). Pooled
funding or insurance schemes can besteps towards reducing out-of-pocket
expenses. Voucher programmes,
performance-based financing,social insurance programmes,and conditional cash transfers tofamilies have improved sexual andreproductive health in a wide rangeof settings (Starrs and others, 2018).
In some countries, there may be arationale to privatize health services,
but this should not be done in waysthat impose costs that poorer andyounger people may not be able
to afford, resulting in losses totheir rights.
Beyond domestic finance, avariety of external factors constrain© Sven Torfinn/Panos Pictures

STAT E OF WOR L D POPUL AT I ON 2 01 9

133

Getting to three zeros
NO unmet need for contraception
NO preventable maternal deaths
NO violence or harmful practices
against women and girls—requires
ambition and commitment.

funds for health care and should
be addressed, starting with thefulfilment of global commitments
to official development assistanceand humanitarian aid. Other
critical challenges include debt
servicing that contradicts human

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rights by imposing onerous
spending restrictions on essential
services.
Measuring the situation

Policies, programmes andinvestments to fully realize

reproductive rights and choicesneed to be grounded in the rightevidence. Data gathering has
improved since the ICPD. Yet gaps
remain in coverage and capacity
for data collection and analysis.
Surveys often remain a stopgap for© Filippo Monteforte/Getty Images

the lack of effective administrative
sources such as civil registration
systems.
Many countries struggle witha lack of disaggregated data,
making it impossible to accurately
understand and respond to what

is happening in marginalized
communities, for instance, or toassess differences by region or
between urban, peri-urban andrural areas. Data on reproductive
health often focus on married
women of reproductive age,
without sufficient consideration
for single women, younger andolder people, or LGBTI people.
Only about one third of all
countries and territories havereliable data on maternal mortality(UN Women, 2018). Other
major gaps involve measuring
financial resources dedicated tosexual and reproductive healthand rights, the scope of unpaid
care work, the surveillance ofsexually transmitted infections,and the extent of gender-based
violence. Intersections among
multiple forms of discrimination
are poorly tracked, as are changes
in population age structure, despite
their profound impact
on development.
The emphasis on monitoringin the 2030 Agenda provides
opportunities to close these gaps,
particularly since monitoring
progress towards the ICPD
contributes directly to core aimsof the SDGs. Upcoming roundsof censuses starting in 2020 canbe oriented around updating anddisaggregating data in the context
of the 2030 Agenda, applying
new technologies and developing
innovations. Increasingly,
technology offers options toimprove data collection, suchas through the use of geospatial
information or handheld electronic
devices. Modelling tools available
in open source software offer new
options to apply data in assessing
interactions across different
dimensions of population, sexualand reproductive health and rights,
and sustainable development.

Getting to three zeros
Over the past 50 years, change has
worked its way through people’s
lives and across generations. Many
women today have better lives
than their mothers, and can hopefor even more for their daughters.
That hope rests largely on
realizing sexual and reproductive
rights and choices for everyone.
Getting to three zeros—nounmet need for contraception, no
preventable maternal deaths, andno violence or harmful practices
against women and girls—requires
ambition and commitment. Many
obstacles lie ahead along a paththat is neither straightforward
nor uncontested. But people
have already gone far in claiming
their rights and choices, and willcontinue to do so. History is on
their side.

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135

© UNFPA/M. BradleyCHAPTER 9

MORE THAN
MY MOTHER,LESS THAN
MY DAUGHTER

They are 35 years old. They have had all their children. Are still having
children. Or are thinking about it. Unlike many of their mothers, they
have mostly not stayed home to work. They are community leaders andfamily breadwinners, among many other roles.

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137

Many have dreamed dreams thatnever occurred to their mothers.
They have services and chances toearn an income that have allowed
them to claim some of their reproductive rights and choices. Someof these became available as a resultof the International Conference
on Population and Development(ICPD), which happened when
they were just 10 years old.
But especially for women at thelow, sharp end of the economy,rights and choices have been
partially realized at best. The
constraints are many: limited
education, the absence of decent
work, the rising cost of health care.
Even those in higher-level jobs canstill face steep financial penalties
related to childbearing and caring.
Has the world kept its promises
to the post-Cairo generation?
Not entirely. Not yet.
These 35-year-old women are
hopeful and courageous. They
believe that the future will be betterfor their children. For now, though,their experiences tell a story of how
far we have come and just how
much more needs to be done.

138

CHAPTER 9© UNFPA/M. Bradley“I have experiences and know
things, but a diploma would
recognize what I can do.”
Fanie
Haiti: lost chancesfor education
Fanie Derismé was born high in themountains outside the capital of Haiti,
Port-au-Prince, and was one of 13
children crammed into a three-roomhouse. Her parents had a thriving
garden to feed the family, and hermother was renowned as a butcher.
But the pressures of a large family
encouraged a decision to take Fanieout of school at age 10 so that she
could work in the home of a cousin in
the city. The hope was that she wouldfind opportunities to continue her
education. Those dreams soon fadedin the exhaustion of time-consuming
household chores, and in a second
family, regular abuse.
By 20, Fanie had fallen in love and waspregnant. That had not been the plan,but no one had ever told her anythingmore than it might be dangerous
to get “too close” to a man. At thesix-month mark, her boyfriend left
her for another woman, and Fanie
had her son on her own. Today, heis 15 and in school, but Fanie isunder constant stress to make ends
meet. She cleans homes for income,and wishes she had taken her own
schooling more seriously so that she
could have pursued her dream of
becoming a cook, maybe opening asmall restaurant.
“I have experiences and know things,
but a diploma would recognize what
I can do,” she says. “I have had toaccept so much, like living in otherpeople’s houses, doing all the workand constant humiliation. I hope myson will learn and become somebody,and live much better than I have.”
She would like another child but isconcerned about costs and the lackof a stable relationship. “I do notwant to be with a man, have a child,see it doesn’t work, and be alone in© UNFPA/R. Aniscarrying out all the responsibilities,”
she says. “Only with two incomes
would I be in a position to sustaina child.”
For now, she relies on condoms
to avoid pregnancy, but they havebecome expensive; public clinics do
not always freely provide them as
was once the case.
Other pressures come from her
sisters, who have many more children
and expect her to help them out.
One sister gave two children to
an international organization thatpromised to educate them and returnthem at age 18, but they never cameback. No one knows where they are.
© UNFPA/M. Bradley“I have not seen
the changes
that people talkabout.”Um Ahmed

Egypt: a struggle forincome and healthBorn in a poor neighbourhood of
Cairo, the birthplace of the ICPD
Programme of Action, Um Ahmed
says simply, “I have not seen
the changes people talk about.”
Poverty ended her education after
primary school. Until she marriedat 27, she toiled in odd jobs as aseamstress and domestic helper,
scraping together enough money
for the household furnishings thata bride is expected to bring to a
new union.

139© UNFPA/R. Anis

There were two pregnancies inquick succession, ending in two
premature births and the deaths ofher children. Surgery in a public
hospital helped her carry a third
pregnancy long enough for her
son Ahmed, now 6, to make itinto the world.
Along the way, Um Ahmedlearned that years of working longhours for little pay had taken apermanent toll. She contracted avirus that can complicate pregnancies. With a meagre income
insufficient for basic health care,such as regular prenatal visits tothe doctor, she had to borrow frommultiple family members to cover
the extra costs of carrying one
child to term.

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CHAPTER 9

Um Ahmed’s mother had fivechildren and worked only in
her home. Um Ahmed has one
child and has decided not tohave another because she simply
cannot earn enough, despite
yearning for Ahmed to have asibling. The cost of living always
goes beyond her means. “If I
want to keep a child, I will needto go through checkups andsurgery again, but it is too muchof a financial burden. I work so
hard but things never seem toimprove,” she laments.
Her husband wants morechildren and disputes her choice
to use an intrauterine device,although his employment
as a labourer is sporadic andmarginal. Sometimes, when thearguments escalate, he beats her
and shouts that God will provide
the income they need. She knows
about the hotline she can call toseek protection from him, yet she isafraid that a permanent separation
might rupture the relationship withher son.
When Um Ahmed was 10, she wasa dedicated student, walking anhour to school and an hour backeach day because her family could
not afford transport. She dreamedof going to university and getting
a decent job with a comfortable
house. Now that dream is only forher son. “I am determined, until
my last breath, that he will stay inschool and have a dignified life.”

Guinea-Bissau: seeking astable partnership
On the western tip of Africa in
Guinea-Bissau, Marta Paula Sanca
finished secondary school and has
a better job than either Um Ahmed
or Fanie, even though she started
her education under a tree in apoor neighbourhood of Bissau,
the capital. She and her brotherwere only two of five siblings tosurvive childhood.
When she was 13 and going to
the market to fetch items for her
mother, a man started talking to
her and buying her sweets. She
did not understand what was
happening when he raped her—or when she became pregnant.
She remembers staying at thehospital for some time before thebirth because she was so youngthat doctors were concerned she
might die. They also discouraged
her parents from authorizing an
abortion, stating that it too poseda risk to her life. They insisted thateven if Marta Paula died later in the
pregnancy, at least the baby mightsurvive. In the end, the delivery
happened without incident.
Not long after, in the late 1990s,
civil conflict took the life of her

father, and her mother became
ill. As a teenage mother, Marta
Paula was expected to go towork to help her younger brotherand her mother. Somehow, shemanaged child-rearing, working
in a cleaning job, selling items on
the street and finishing secondary

school. She started a
relationship that promised to
be a stable one, and she andher partner decided to haveanother child when she was
19. But the father, travelling
frequently as a driver, later
left her for another woman.

“I would tell all mothers in
Guinea-Bissau that when girls reach
12, look for family planning services
and choose a contraceptive method.”
Marta Paula© UNFPA/I. Barbosa

© UNFPA/I. Barbosa

Today she works as a security guard
and wishes she could have morechildren. But like Fanie, she will
not do so unless she finds a stable
relationship, which so far remains
elusive. Long hours on the job
mean that her children are often
still asleep in the morning when she
leaves, and have gone to bed when
she returns at night.
She worries about changing norms
in her country, now awash in
information from the rest of theworld. Her pregnancy at 13 wasconsidered extremely unusual for

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CHAPTER 9

the time. “But today, it is very
common,” she says, attributing theshift to more permissive parenting
and sexual activity at younger ages.
Poverty too plays a role, driving
some girls to trade their bodies forschool fees and money needed bytheir families.

stresses, “I would tell all mothersin Guinea-Bissau that when girls
reach 12, look for family planning
services and choose a contraceptive
method.”Family planning information
is well disseminated, andreproductive health services arefor the most part available, yet
teenage girls are somehow notbeing reached. Both of Marta
Paula’s children are boys, but she

Married at 15, Mediha Besic firstbecame a mother at 16. At 35,
she has five children, ranging
in age from 4 to 19. Part of amarginalized Roma community
in a rural area of Bosnia andHerzegovina, she and her husband

Bosnia and Herzegovina:
constrained choices forcontraceptionfind themselves too poor topurchase modern contraception,
relying instead on traditional, lesseffective options like withdrawal.
“It would have been easier toraise two kids,” Mediha says.
“I wanted to use contraception,
but when you have no money,
it is not affordable.”
Like her mother before her,
Mediha works only at home.
Her husband used to collectand sell leftover construction
materials, but that businesshas diminished over the years,
with supplies drying up and gas
becoming more expensive. Now
he finds work only occasionallyas a day labourer. For the mostpart, the family survives on a
publicly provided child allowanceof about $50 per month, hardly
above the global definition of
extreme poverty.
Still, Mediha feels that her life
has improved in some ways since
she was a child—and certainly
since the war that consumed her
country in the 1990s, when she
remembers never having enoughto eat. Today she lives in a larger
home than the one she grew up in.
It is constructed of brick and not

scrap materials, although still
has no running water.
Having finished primaryschool, she can read and write.
By contrast, her mother never© UNFPA/I. Kapetanović

“I wanted to use contraception,
but when you have no money,
it is not affordable.”
Mediha© UNFPA/I. Kapetanović© UNFPA/I. Kapetanović

saw the inside of a classroom.
Yet Mediha is very far from achildhood ambition to be ateacher or doctor. “My parents
had six children and could not
pay for schooling for all of us, so
I had to drop out.” A sister who
did finish school went on
to become a nurse.
The first time Mediha ever saw agynaecologist was when she wasfive months pregnant with her
first child. The doctors talked
to her mostly about the baby
and her delivery, but shared

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little information on planning
future pregnancies. “In our
culture, you don’t talk to anyone
about family planning,” shesays, remembering how she felt
ashamed and shy.
Today, though, she has madesure to talk to her oldest twochildren about how they canprotect themselves. “I wantthem to finish school, find a
job and then to get married andhave their own families,” shesays. “I feel optimistic that they
will have better chances in life.”

Brazil: a father
encourages adifferent life
It was only about 70 years agothat Tsitsina Xavante’s indigenous
community, the A’uwe Uptabi,
first made contact with the outside
world in Brazil. Before that, they
kept to themselves, deep in therainforest. Her father wore no
clothes as a young man and spoke
no Portuguese. When he became
Brazil’s first indigenous memberof Congress, he took Tsitsina, his
youngest child, to live with him
in Brasilia, the capital. Her earlyexperiences led her to become aleader of the Namunkurá Xavante
Association, which represents 305
different indigenous groups. She
is careful to say that she does not
speak for all indigenous people,
only herself.
Among 10 siblings, she is the
only one who finished college andeven a master’s degree. So far, she
has chosen not to marry, and not© UNFPA/G. Bello“They believe that I have a
responsibility to have children,
to give continuity to our people,
but they also realize that I have
lived in a different way.”
Tsitsinato have a child, at least not yet.
Before her father died in 2002,
when she asked him for permission
to start dating at the age of 15, herefused. “He wanted me to study
longer so I could go anywhere I
want,” she recalls. “He said even
if I marry I should be financiallyindependent.”
Recently, however, her married
sisters have been urging her tohave a son or daughter before it
is too late. In the tradition of her
polygamous community, it would
be acceptable to have a relation© UNFPA/G. Belloship with a brother-in-law to
get pregnant. “They believe that
I have a responsibility to havechildren, to give continuity to
our people,” Tsitsina says. “Butthey also realize that I have lived
in a different way.”
Her concerns about her community include the observationthat many people used to wait tohave a second child until the firstwas a toddler, but now women
typically have children once a
year for many years. Disease risks
have risen given the practice of

having multiple sexual partners
within families. Indigenous healthcare is available, yet not regularly
used. Extreme taboos around speaking openly about sex and sexuality
mean many people have little to no
information about their own bodies
or know how to explore sex withresponsibility.
“Many girls will get married at 14
or 15 and have kids really young,”
Tsitsina says. “Some are happy withthis. But they never learn otherperspectives. I would like them to,because otherwise you will always
just stick with the life you alreadyknow and see as natural, with nonew stimuli.”
It is not easy. Her community
has no Internet access, although
it is now connected to electricity.
Getting a boat to the closest city,
the only means of transport, isexpensive. And in a patriarchal
society, where women’s well-definedroles and work are dismissed as lessvaluable, it can be extraordinarily
hard for girls to muster motivation
to follow their dreams. They can,however, look to Tsitsina as amodel, someone committed to hercommunity even as she lives in a
new way.

© UNFPA/Lexicon“I am lucky that today I havemore opportunities becauseof my parents’ support.”

in economics and international
business, urged on by her mother,
who only finished school throughfifth grade. Growing up, Rasamee
watched her parents struggle
financially. Her mother worked athome and her father sought jobs inconstruction, but was often derailed
by illness.

RasameeThailand: a changing
culture“I love my work,” Rasamee
exclaims, quickly sketching her roleas chief advocate for sustainable
development within Thailand’s
leading telecommunications
company. It’s a high-pressure
job with long hours. She must
strategize with managers andcorporate board members on what

could be fundamental changes in
the way the company does businessover the longer term. But she’s up
to the challenge just five months
after giving birth to her first child.
It’s a far cry from the era of her
grandparents, who emigrated toThailand from China, and believedthat school was for boys and home
was for girls. Rasamee has a degree“I am lucky that today I havemore opportunities because of myparents’ support,” she says. “I used
to think about how I wanted aprosperous life. But we were always
aware of how many other people
were suffering, so that meant notjust that I have enough to feed
myself, but that I can live a life of
purpose.” Her current job includes
thinking through how the company

STAT E OF WOR L D POPUL AT I ON 2 01 9147

can help Thailand advance on the
Sustainable Development Goals.
Rasamee thrived as a professional
for many years before eventhinking about getting married,
not long before having her firstchild. “The culture has changed,”she says. “Women can work andtake care of themselves and don’t
need to rely on their husbands.”
Support for that freedom comesfrom the information about familyplanning that is widely available
and routinely taught in schools.
Contraception is available inpractically every corner shop.
“Our Government has promoted
this so much,” Rasamee says.
She believes that “no one isembarrassed to talk about it.”After giving birth, she was soeager to return to her job that
she took only two months
for maternity leave, despite acorporate provision allowing

three. She plans to have anotherchild, but not the three or fourthat used to be common in her
community.
“My husband also works—wewould never have enough time
for that many babies!” she laughs.
The two are already working
together on an education fund
for their newborn, and herhusband has a plan to expand hisbusiness to sustain the costs of a
growing family.
© UNFPA/Lexicon

Sri Lanka: an unexpected
gift—children after cancer
Growing up in Sri Lanka,
Shara Ranasingh’s early life wastumultuous. Her parents had
divorced and the court stipulated
that she, a single child, live withher father because he had financial
stability and her mother did
not. “My mother was a brilliant
child, but she never went beyond
secondary school, and she married
and had a child by 20,” Shara says.
After her father remarried,
Shara suffered at the hands of astepmother, who beat her at times.
When her own mother asked what
had happened, she would make up
excuses like she had fallen on thestairs, not wanting to stir up moreconcern and anger.
Despite her unhappy childhood,
Shara emerged with an independentand resilient spirit. After moving
to Malaysia to pursue a university
degree, she began to thrive untilin her final year of studies she wasdiagnosed with cancer. She told her
boyfriend that he really ought toleave her, but he refused, standingby her side through gruelling roundsof chemotherapy and radiation.

© UNFPA/C. Learson“My mother was a brillant child,but she never went beyond secondary
school, and she married and hada child by 20.”
Shara
When it was over, the doctors said
there was a low to zero probability
that she would ever bear children.
At one point, she had been asked
if she wanted to preserve her
eggs, but the subject came up in
front of her father and felt too
uncomfortable for discussion.
She and her boyfriend decided
to marry anyway, and soon after
she found she was pregnant. “Thestick turning positive was the bestthing that ever happened in mylife,” she confides.

Two more children have followed
since then, and Shara has moved
to Australia to pursue advanced
degrees, aiming for a doctorate
in communications with cancer
patients. While she always wanted
many offspring, each pregnancy
poses some risk to her fragile health.
Financially, too, three feels like theright number. While Australia has
subsidized childcare, she and herhusband have worried about being
away from their small children
and juggled their work so that one

STAT E OF WOR L D POPUL AT I ON 2 01 9

149parent could always be homewith them.
At one point, Shara moved aheadin her teaching career and became
the main family breadwinner,
while her husband took time offfrom being an engineer to work
flexible hours preparing food incafes. More recently, his parents
have come to live with the couple,
and her husband has gone back toengineering.
© UNFPA/C. Learson

In the world around her, she seesa growing openness, with women
finally moving into leadership
positions at her university, and a
boy at her daughter’s school who
has, for the first time, asked to betreated as a girl. Her first “miracle”
daughter is now approaching 10,
a talented, sensitive child. “I want
her to be very strong,” Shara says.
“I hope she does not encounter
discrimination, but there are still
so many inequalities.”

She counts Australia as further
ahead in understanding a changing
world, compared to Sri Lanka,
where she says the majority ofpeople retain deeply conservative
expectations of women. She enjoys
the staunch support of her parents
in making choices to pursue her
dreams. But, she says, “my country
has a few more years to go. I am
hopeful that future generations
will be born into a Sri Lanka that
fosters equal opportunities for all.”Indicators
Indicators for monitoring ICPD goals

page 152

Demographic indicators

page 164

Technical notes

page 170

STAT E OF WOR L D POPUL AT I ON 2 01 9

151

Indicators for monitoring ICPD goals
SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

COUNTRIES,WORLDAND TERRITORIESAND OTHERAREAS
AREAS
REGIONAL

Contraceptive
prevalence
rate, women
aged 15-49,
any methodʄ

Contraceptive
prevalence
rate, women
aged 15-49,
modern methodʄ

2019

1969* 1994 2019

Unmet
need for
Proportion
familyof demandplanning,
satisfied,
women
women
ʄ
aged 15-49 aged 15-49ʄ

2019

2019

Birthsattendedby skilled
healthpersonnel,
per cent

Decisionmaking on
sexual andreproductive
health andreproductive
rights, per cent

Proportion ofdemand satisfied
with modern
methods, women
aged 15-49ʄ

Maternal
mortality ratio(MMR)(deaths
per 100,000
live births)a

1969* 1994 2019

1994
1994*

2015

2015

2015

2006-20172017

2007-20182014

Range of MMR
uncertainty (UI 80%),
Lower
Upper
estimate estimate

WORLD

63

24

52

58

12

84

42

72

78

369

216

207

249

79

57

More developed regions

68

35

57

61

10

88

46

72

79

22

12

11

14

–

–

Less developed regions

62

20

51

57

12

84

40

72

77

409

238

228

274

–

Least developed countries

42

1

15

37

21

67

4

31

59

832

436

418

514

56

54

11

33

48

15

78

26

54

69

285

162

138

212

76

–
d

49

REGIONAL DATA
Arab States
Asia and the Pacific

67

22

58

62

10

87

45

78

81

316

127

114

151

84

Eastern Europe and Central Asia

66

16

36

50

10

87

24

49

66

68

25

22

31

98

–
b

–
–

Latin America and the Caribbean

74

25

57

70

10

89

39

71

83

117

68

64

77

95

East and Southern Africa

42

2

14

38

22

66

6

29

60

858

455

419

556

62

51

West and Central Africa

22

0

6

18

24

47

1

17

39

1040

676

586

862

52

38

COUNTRIES, TERRITORIESAND OTHER AREAS

2019

1969* 1994 2019

2019

2019

1969* 1994 2019

1994

2015

2015

2015

2006-20172007-2018c–

Afghanistan

27

1

6

24

24

52

5

17

48

1300

396

253

620

51

–

Albania

64

7

14

26

14

82

9

18

33

49

29

16

46

99

69

Algeria

64

13

46

57

10

87

30

67

77

196

140

82

244

97

–

Angola

17

0

3

16

36

33

1

8

30

1180

477

221

988

50

62

Antigua and Barbuda

64

29

53

61

13

83

47

72

80

–

–

–

–

–

–

Argentina

69

19

48

66

11

86

34

66

82

64

52

44

63

100

–

Armenia

59

15

26

31

13

82

26

35

44

50

25

21

31

100

66

Aruba

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Australia

66

62

66

64

11

86

80

85

83

8

6

5

7

100

–

Austria

67

28

50

64

10

88

39

71

84

7

4

3

5

98

–

Azerbaijan

58

11

18

29

13

82

23

27

40

92

25

17

35

100

–

Bahamas

67

40

61

65

12

85

60

79

83

47

80

53

124

–

–

Bahrain

67

17

33

48

10

87

30

46

63

22

15

12

19

100

–

Bangladesh

64

3

37

57

11

85

9

55

76

495

176

125

280

50

–

Barbados

62

35

54

59

15

80

54

72

76

56

27

19

37

99

–

Belarus

73

18

39

60

7

91

25

54

75

33

4

3

6

100

–

Belgium

72

22

69

71

7

91

27

88

90

9

7

5

10

–

–

Belize

55

20

42

52

19

74

35

60

70

55

28

20

36

97

–

Benin

21

0

3

15

30

41

1

7

30

541

405

279

633

77

38

Bhutan

63

3

22

62

12

84

10

44

83

690

148

101

241

89

–

Bolivia (Plurinational State of)

66

5

18

49

15

81

9

25

59

401

206

140

351

90

–

Bosnia and Herzegovina

50

3

12

21

15

77

5

19

33

24

11

7

17

100

–

Botswana

60

3

38

58

14

82

6

60

79

230

129

102

172

100

–

Brazil

80

35

68

77

7

92

49

79

88

88

44

36

54

99

–

152

I NDICATOR S

Indicators for monitoring ICPD goals
SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

COUNTRIES, TERRITORIESAND OTHER AREAS
Brunei Darussalam

Contraceptive
prevalence
rate, women
aged 15-49,
any methodʄ

Contraceptive
prevalence
rate, women
aged 15-49,
modern methodʄ

Unmet
need forfamilyplanning,
women
aged 15-49ʄ

2019

1969* 1994 2019

2019

2019

–

–

–

–

–

–

Proportionof demandsatisfied,
women
aged 15-49ʄ

Proportion ofdemand satisfied
with modern
methods, women
aged 15-49ʄ

Maternal
mortality ratio(MMR)(deaths
per 100,000
live births)a

1969* 1994 2019

1994

2015

2015

34

23

15

–

–

–

Birthsattendedby skilled
healthpersonnel,
per cent

Decisionmaking on
sexual andreproductive
health andreproductive
rights, per cent2015

2006-20172007-2018

30

100

–

Range of MMR
uncertainty (UI 80%),
Lower
Upper
estimate estimate

Bulgaria

72

6

46

54

10

88

7

52

66

25

11

8

14

100

–

Burkina Faso

26

0

4

26

27

50

0

10

48

655

371

257

509

80

20

Burundi

33

0

4

28

27

55

0

11

47

1250

712

471

1050

85

44

Cambodia

61

0

8

46

12

84

1

18

63

789

161

117

213

89

76
38

Cameroon, Republic of

37

0

5

25

20

65

1

14

44

749

596

440

881

65

Canada

72

63

73

70

8

90

81

89

88

8

7

5

9

98

–

Cape Verde

66

2

32

63

12

84

5

50

81

170

42

20

95

91

–

Central African Republic

26

1

3

21

23

53

2

10

42

1320

882

508

1500

40

–

Chad

8

0

1

7

24

24

0

5

22

1440

856

560

1350

20

27

Chile

75

22

53

72

8

90

38

71

86

43

22

18

26

100

–

China

83

44

83

82

4

96

68

95

95

77

27

22

32

100

–

China, Hong Kong SAR

76

40

80

72

7

92

60

90

88

–

–

–

–

–

–

China, Macao SAR

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Colombia

80

12

59

75

7

92

20

71

86

109

64

56

81

99

–

Comoros

27

1

10

22

30

48

3

19

39

576

335

207

536

82

21

Congo, Democratic Republic of the

25

2

4

12

27

49

4

8

23

904

693

509

1010

80

31

Congo, Republic of the

42

2

8

26

20

68

4

16

43

627

442

300

638

91

27

Costa Rica

79

44

68

77

7

92

60

81

89

43

25

20

29

99

–

Côte d’Ivoire

20

0

4

18

25

44

1

11

40

741

645

458

909

74

25

Croatia

65

7

27

48

11

86

10

35

63

12

8

6

11

100

–

Cuba

74

49

68

72

9

90

68

85

88

57

39

33

47

100

–

Curaçao

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Cyprus

–

–

–

–

–

–

–

–

–

17

7

4

12

97

–

Czechia

80

18

47

71

6

93

23

58

83

11

4

3

6

100

–

Denmark

70

55

66

67

10

88

70

82

84

11

6

5

9

94

–

Djibouti

29

0

3

27

28

50

0

8

48

459

229

111

482

87

–

Dominica

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Dominican Republic

71

22

57

69

11

87

37

73

84

181

92

77

111

100

77

Ecuador

79

14

47

71

7

92

27

62

83

147

64

57

71

97

–

Egypt

61

17

46

60

12

84

36

67

82

88

33

26

39

92

–

El Salvador

72

15

50

68

10

88

31

69

82

135

54

40

69

100

–

Equatorial Guinea

19

1

4

15

32

37

2

11

30

1170

342

207

542

68

–

Eritrea

15

0

4

14

30

34

1

10

31

1210

501

332

750

34

–

Estonia

66

35

49

61

11

85

46

64

79

57

9

6

14

100

–

Eswatini

66

2

25

65

14

83

6

40

81

538

389

251

627

88

49

Ethiopia

41

0

3

40

21

66

0

8

64

1130

353

247

567

28

45

Fiji

49

31

39

45

19

72

50

59

66

54

30

23

41

100

–

Finland

83

59

73

78

5

95

72

87

90

5

3

2

3

100

–

STAT E OF WOR L D POPUL AT I ON 2 01 9

153

Indicators for monitoring ICPD goals
SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

COUNTRIES, TERRITORIESAND OTHER AREAS

Contraceptive
prevalence
rate, women
aged 15-49,
any methodʄ

Contraceptive
prevalence
rate, women
aged 15-49,
modern methodʄ

Unmet
need forfamilyplanning,
women
aged 15-49ʄ

2019

1969* 1994 2019

2019

2019

5

94

76

France177074

Proportionof demandsatisfied,
women
aged 15-49ʄ

Proportion ofdemand satisfied
with modern
methods, women
aged 15-49ʄ

Maternal
mortality ratio(MMR)(deaths
per 100,000
live births)a

1969* 1994 2019

1994

2015

2015

14

8

7

22

86

91

Birthsattendedby skilled
healthpersonnel,
per cent

Decisionmaking on
sexual andreproductive
health andreproductive
rights, per cent2015

2006-20172007-2018

10

97

–

Range of MMR
uncertainty (UI 80%),
Lower
Upper
estimate estimate

French Guiana

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

French Polynesia

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Gabon

37

2

10

26

25

60

4

18

42

408

291

197

442

89

48

Gambia

14

1

9

12

26

35

3

23

32

994

706

484

1030

57

41

Georgia

55

9

20

41

15

79

20

35

58

34

36

28

47

100

–

Germany

63

40

65

62

11

85

50

83

83

9

6

5

8

99

–

Ghana

33

2

10

29

27

55

6

18

48

535

319

216

458

71

52

Greece

70

19

32

50

9

89

23

40

64

4

3

2

4

–

–

Grenada

66

18

52

62

12

84

34

71

80

38

27

19

42

–

–

Guadeloupe

59

19

41

55

16

79

33

60

73

–

–

–

–

–

–

Guam

53

23

37

46

16

76

41

57

67

–

–

–

–

–

–

Guatemala

62

10

26

52

14

82

22

44

69

178

88

77

100

63

65

Guinea

10

0

2

9

25

29

0

6

25

967

679

504

927

63

23

Guinea-Bissau

20

0

3

18

21

49

1

12

45

799

549

273

1090

45

–

Guyana

42

19

36

41

27

61

31

53

59

190

229

184

301

86

71

Haiti

37

4

13

34

35

51

7

22

47

551

359

236

601

49

59

Honduras

73

13

39

65

10

88

25

55

78

186

129

99

166

83

70

Hungary

68

30

65

60

10

87

37

77

76

21

17

12

22

–

–

Iceland

–

–

–

–

–

–

–

–

–

6

3

2

6

98

–

India

57

9

39

51

12

82

22

62

74

488

174

139

217

86

–

Indonesia

61

5

52

59

13

83

15

74

80

347

126

93

179

93

–

Iran (Islamic Republic of)

78

16

52

65

5

94

32

66

78

87

25

21

31

99

–

Iraq

58

10

22

44

12

83

25

42

63

92

50

35

69

70

–

Ireland

68

44

61

63

11

87

56

76

81

9

8

6

11

100

–

Israel

72

27

51

57

8

90

43

65

71

9

5

4

6

–

–

Italy

69

15

38

54

9

88

20

50

69

7

4

3

5

100

–

Jamaica

72

33

57

69

10

88

51

74

84

80

89

70

115

99

–

Japan

44

53

54

40

21

68

75

74

62

11

5

4

7

100

–

Jordan

63

16

33

47

12

85

29

48

63

96

58

44

75

100

73

Kazakhstan

57

27

47

55

15

80

44

63

77

86

12

10

15

99

–

Kenya

65

2

27

62

14

82

4

41

79

684

510

344

754

62

56

Kiribati

29

16

24

24

26

52

33

44

45

215

90

51

152

80

–

Korea, Democratic People’s
Republic of

75

29

56

71

8

90

47

72

86

65

82

37

190

100

–

Korea, Republic of

78

19

67

70

6

93

36

80

84

19

11

9

13

100

–

Kuwait

57

16

37

47

15

80

32

58

65

8

4

3

6

100

–

Kyrgyzstan

44

28

47

41

17

72

48

69

68

89

76

59

96

98

77

Lao People’s Democratic Republic

57

1

17

51

17

77

4

32

69

734

197

136

307

40

–

Latvia

69

39

56

62

11

87

50

69

78

61

18

13

26

100

–

154

I NDICATOR S

Indicators for monitoring ICPD goals
SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

COUNTRIES, TERRITORIESAND OTHER AREAS
LebanonContraceptive
prevalence
rate, women
aged 15-49,
any methodʄ

Contraceptive
prevalence
rate, women
aged 15-49,
modern methodʄ

Unmet
need forfamilyplanning,
women
aged 15-49ʄ

2019

1969* 1994 2019

2019

2019

13

83

61

24

38

48

Proportionof demandsatisfied,
women
aged 15-49ʄ

Proportion ofdemand satisfied
with modern
methods, women
aged 15-49ʄ

Maternal
mortality ratio(MMR)(deaths
per 100,000
live births)a

1969* 1994 2019

1994

2015

2015

57

15

10

36

51

65

Birthsattendedby skilled
healthpersonnel,
per cent

Decisionmaking on
sexual andreproductive
health andreproductive
rights, per cent2015

2006-20172007-2018

22

–

–

Range of MMR
uncertainty (UI 80%),
Lower
Upper
estimate estimate

Lesotho

62

1

22

61

16

79

2

37

79

522

487

310

871

78

61

Liberia

31

1

8

31

28

53

4

18

52

1890

725

527

1030

61

67

Libya

51

10

25

34

18

74

21

38

49

27

9

6

15

100

–

Lithuania

66

28

37

56

11

85

39

51

73

31

10

7

14

–

–

Luxembourg

–

–

–

–

–

–

–

–

–

13

10

7

16

100

–

Madagascar

47

0

7

41

18

72

1

15

63

676

353

256

484

44

74

Malawi

62

0

11

61

16

79

1

21

77

956

634

422

1080

90

47

Malaysia

53

13

34

39

17

76

27

48

56

67

40

32

53

99

–

Maldives

45

7

25

38

23

67

16

41

56

370

68

45

108

96

–

Mali

16

0

4

16

26

39

0

11

38

940

587

448

823

44

7

Malta

84

26

54

67

4

96

29

60

76

13

9

6

15

100

–

Martinique

61

24

46

57

15

80

39

64

75

–

–

–

–

–

–

Mauritania

21

0

2

19

30

41

0

6

37

827

602

399

984

69

–

Mauritius

67

17

46

44

10

87

27

57

57

68

53

38

77

100

–

Mexico

71

17

57

68

11

87

29

71

82

86

38

34

42

98

–

Micronesia (Federated States of)

–

–

–

–

–

–

–

–

–

169

100

46

211

85

–

Moldova, Republic of

64

18

39

49

12

84

23

50

65

63

23

19

28

99

–

Mongolia

58

22

44

52

14

81

41

62

73

208

44

35

55

99

–

Montenegro

39

8

22

24

21

65

11

33

41

12

7

4

12

99

–

Morocco

70

8

41

62

9

89

21

61

79

264

121

93

142

74

–

Mozambique

30

0

5

29

24

56

1

16

53

1210

489

360

686

54

49

Myanmar

54

2

21

53

15

78

6

43

76

389

178

121

284

60

68

Namibia

60

3

31

59

16

79

8

55

78

323

265

172

423

88

71

Nepal

54

1

23

48

22

71

4

40

63

693

258

176

425

58

48

Netherlands

72

49

73

69

8

91

64

89

86

13

7

5

9

–

–

New Caledonia

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

New Zealand

71

52

69

68

9

89

70

85

85

14

11

9

14

96

–

Nicaragua

80

11

50

77

6

93

21

66

90

199

150

115

196

88

–

Niger

21

0

3

19

19

52

1

13

48

836

553

411

752

40

7

Nigeria

19

0

8

15

23

45

1

23

36

1270

814

596

1180

43

51

North Macedonia

48

3

11

23

18

73

5

16

35

12

8

5

10

100

–

Norway

75

55

64

70

7

91

70

80

84

7

5

4

6

99

–

Oman

38

3

16

26

25

60

8

30

41

21

17

13

24

99

–

Pakistan

42

3

14

33

19

68

9

30

54

375

178

111

283

52

–

Palestine 1

60

12

30

47

12

83

26

48

65

101

45

21

99

100

–

Panama

60

37

53

57

16

79

53

71

75

85

94

77

121

95

–

Papua New Guinea

37

15

20

31

25

60

29

36

50

388

215

98

457

53

–

Paraguay

72

14

41

68

9

89

28

57

85

147

132

107

163

96

–

Peru

76

10

39

56

7

92

16

48

68

215

68

54

80

92

–

STAT E OF WOR L D POPUL AT I ON 2 01 9

155

Indicators for monitoring ICPD goals
SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

COUNTRIES, TERRITORIESAND OTHER AREAS

Contraceptive
prevalence
rate, women
aged 15-49,
any methodʄ

Contraceptive
prevalence
rate, women
aged 15-49,
modern methodʄ

Unmet
need forfamilyplanning,
women
aged 15-49ʄ

2019

1969* 1994 2019

56

Philippines

1127

Proportionof demandsatisfied,
women
aged 15-49ʄ

Proportion ofdemand satisfied
with modern
methods, women
aged 15-49ʄ

Maternal
mortality ratio(MMR)(deaths
per 100,000
live births)a

1969* 1994 2019

1994

2015

2015

121

114

87

2019

2019

42

17

77

20

37

57

Birthsattendedby skilled
healthpersonnel,
per cent

Decisionmaking on
sexual andreproductive
health andreproductive
rights, per cent2015

2006-20172007-2018

175

73

81

Range of MMR
uncertainty (UI 80%),
Lower
Upper
estimate estimate

Poland

61

12

33

52

14

82

16

42

69

14

3

2

4

100

–

Portugal

70

21

55

63

9

89

26

67

80

15

10

9

13

99

–

Puerto Rico

78

52

67

70

6

93

69

81

84

25

14

10

18

–

–

Qatar

47

15

32

41

17

74

32

54

65

29

13

9

19

100

–

Reunion

73

18

67

71

8

90

29

83

87

–

–

–

–

–

–

Romania

70

3

17

58

8

89

4

23

74

81

31

22

44

95

–

Russian Federation

69

20

46

58

9

88

26

60

74

88

25

18

33

99

–

Rwanda

57

0

10

52

17

77

0

17

70

1270

290

208

389

91

70

Saint Kitts and Nevis

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Saint Lucia

59

31

48

56

16

79

51

68

75

40

48

32

72

99

–

Saint Vincent and the Grenadines

66

34

57

63

12

84

52

76

81

74

45

34

63

–

–

Samoa

30

17

23

28

41

42

28

34

39

125

51

24

115

83

–

San Marino

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

São Tomé and Príncipe

44

4

20

41

29

60

8

33

56

271

156

83

268

93

46

Saudi Arabia

31

11

26

25

26

54

24

46

43

36

12

7

20

–

–

Senegal

26

0

6

24

25

51

1

15

48

511

315

214

468

59

7

Serbia

58

4

22

28

13

82

6

30

40

16

17

12

24

98

–

Seychelles

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Sierra Leone

20

0

3

19

26

44

1

9

42

2900

1360

999

1980

60

40

Singapore

66

46

53

59

11

86

64

70

77

12

10

6

17

100

–

Sint Maarten

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Slovakia

72

15

42

61

9

89

19

53

76

10

6

4

7

–

–

Slovenia

77

13

57

66

6

93

17

66

79

13

9

6

14

100

–

Solomon Islands

32

16

24

27

25

56

33

44

48

288

114

75

175

86

–

Somalia

31

0

6

30

27

53

1

15

52

1200

732

361

1390

9

–

South Africa

57

16

52

57

14

80

29

74

79

69

138

124

154

97

–

South Sudan

10

0

1

7

30

24

0

3

18

1580

789

523

1150

19

–

Spain

69

9

55

67

11

87

12

67

85

6

5

4

6

–

–

Sri Lanka

65

17

49

54

8

90

32

64

74

69

30

26

38

99

–

Sudan

17

3

7

16

28

38

8

18

36

667

311

214

433

78

–

Suriname

53

22

43

52

19

74

38

64

73

174

155

110

220

90

–

Sweden

69

53

60

63

10

87

66

76

80

7

4

3

5

–

–

Switzerland

73

48

73

69

7

91

61

87

86

8

5

4

7

–

–

Syrian Arab Republic

60

12

30

45

14

81

25

46

61

94

68

48

97

96

–

Tajikistan

36

15

28

33

21

63

33

50

58

140

32

19

51

87

33

Tanzania, United Republic of

43

1

12

37

21

67

2

26

58

979

398

281

570

64

47

Thailand

78

18

72

76

6

93

38

89

90

25

20

14

32

99

–

Timor-Leste, Democratic Republic of

29

7

20

26

25

54

22

54

49

958

215

150

300

57

40

Togo

23

0

6

21

33

42

1

9

38

566

368

255

518

45

30

156

I NDICATOR S

Indicators for monitoring ICPD goals
SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

COUNTRIES, TERRITORIESAND OTHER AREAS

Contraceptive
prevalence
rate, women
aged 15-49,
any methodʄ

Contraceptive
prevalence
rate, women
aged 15-49,
modern methodʄ

Unmet
need forfamilyplanning,
women
aged 15-49ʄ

2019

1969* 1994 2019

Tonga

36

18

25

Proportionof demandsatisfied,
women
aged 15-49ʄ

Proportion ofdemand satisfied
with modern
methods, women
aged 15-49ʄ

Maternal
mortality ratio(MMR)(deaths
per 100,000
live births)a

1969* 1994 2019

1994

2015

2015

93

124

57

2019

2019

33

27

57

33

42

51

Birthsattendedby skilled
healthpersonnel,
per cent

Decisionmaking on
sexual andreproductive
health andreproductive
rights, per cent2015

2006-20172007-2018

270

96

–

Range of MMR
uncertainty (UI 80%),
Lower
Upper
estimate estimate

Trinidad and Tobago

48

36

41

44

21

70

55

61

64

80

63

49

80

97

–

Tunisia

67

16

49

57

9

88

33

69

76

114

62

42

92

74

–

Turkey

75

11

36

51

6

92

19

46

63

87

16

12

21

97

–

Turkmenistan

55

28

50

52

15

79

48

69

74

88

42

20

73

100

–

Turks and Caicos Islands

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Tuvalu

–

–

–

–

–

–

–

–

–

–

–

–

–

93

–

Uganda

40

0

7

36

28

59

1

16

53

692

343

247

493

74

62

Ukraine

67

17

38

54

10

87

22

49

70

49

24

19

32

99

81

United Arab Emirates

51

8

23

42

18

74

19

42

62

13

6

3

11

100

–

United Kingdom

79

61

78

79

6

93

75

92

93

11

9

8

11

–

–

United States of America

74

53

70

67

7

91

71

86

83

12

14

12

16

99

–

United States Virgin Islands

68

34

55

64

11

86

52

73

80

–

–

–

–

–

–

Uruguay

79

52

76

76

7

92

65

87

89

36

15

11

19

98

–

Uzbekistan

68

27

51

64

9

88

48

74

84

37

36

20

65

100

–

Vanuatu

46

17

31

40

23

67

33

50

59

192

78

36

169

89

–

Venezuela (Bolivarian Republic of)

73

29

56

68

11

87

42

70

82

93

95

77

124

96

–

Viet Nam

79

9

46

65

6

94

20

59

77

113

54

41

74

94

–

Western Sahara

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Yemen

44

1

8

37

24

64

2

15

55

507

385

274

582

45

–

Zambia

55

1

12

51

18

75

2

24

70

597

224

162

306

63

47

Zimbabwe

67

5

43

66

10

87

11

64

86

427

443

363

563

78

60

NOTES
−

Data not available.

*

Figures in this column are listed as 1969 and 1994 to conform with key dates covered in thisreport: 1969 through 2019. The 1969 figures are actually estimates from 1970 and 1994 figures
are estimates from 1995.

ʄ

Women currently married or in union.

a

The MMR has been rounded according to the following scheme: <100, rounded to nearest 1;
100-999, rounded to nearest 1; and ≥1000, rounded to nearest 10.

b

Excludes Cook Islands, Marshall Islands, Nauru, Niue, Palau, Tokelau, and Tuvalu due to data
availability.

c

Excludes Anguilla, Aruba, Bermuda, British Virgin Islands, Cayman Islands, Curaçao,Montserrat, Sint Maarten, and Turks and Caicos Islands due to data availability.

dExcludes Tuvalu due to data availability.

1

On 29 November 2012, the United Nations General Assembly passed Resolution 67/19, whichaccorded Palestine “non-member observer State status in the United Nations...”STAT E OF WOR L D POPUL AT I ON 2 01 9

157

Indicators for monitoring ICPD goals
ADOLESCENTS AND YOUTH

COUNTRIES,WORLDAND TERRITORIESAND OTHERAREAS
AREAS
REGIONAL

Adjusted net enrolment
rate, primary education,
cent,
2017
perpercent,
2009-2018

Adolescent birthrate per 1,000 girls
aged 15-19

Child marriage
by age 18,
per cent

FGM prevalence
among girls aged
15-19, per cent2017
2004-2017

male

2018
2006-20172017
2006-2017

WORLD

44

21

–

92

More developed regions

14

–

–

97

Less developed regions

48

–

–

91

Least developed countries

91

40

–

21

55

femaleGender parity
index, primaryeducation

Net enrolment rate,secondary education,
cent,
2017
perpercent,
2009-20182017
2009-2018

male

90

0.98

97

1.00

89

83

85

Gender parity
index, secondary
education

female2017
2009-2018

66

66

1.00

93

93

1.01

0.98

62

62

0.99

80

0.96

38

36

0.95

83

0.97

63

59

0.93

REGIONAL DATA
Arab States

50

Asia and the Pacific

28

26

–

95

94

0.99

67

68

1.02

Eastern Europe and Central Asia

26

11

–

96

95

1.00

88

87

0.99

Latin America and the Caribbean

62b

26

–

95

96

1.01

75

79

1.05

East and Southern Africa

93c

35

–

86

83

0.97

35

33

0.93

West and Central Africa

114

42

22

79

71

0.90

39

34

0.86

COUNTRIES, TERRITORIESAND OTHER AREAS

2006-2017

2006-2017

2004-2017

male

female2009-2018

male

female2009-2018

Afghanistan

87

35

–

–

–

–

62

36

0.58

Albania

20

10

–

98

96

0.99

88

87

0.99

a

2009-20182009-2018

Algeria

12

3

–

100

98

0.98

–

–

–

Angola

163

30

–

89

66

0.75

13

10

0.79

–

–

–

82

81

0.99

73

76

1.04

Argentina

65

–

–

100

99

0.99

87

92

1.05

Armenia

24

5

–

92

92

1.00

87

88

1.01

Antigua and Barbuda

Aruba

35

–

–

99

99

1.00

73

81

1.10

Australia

12

–

–

96

97

1.01

93

94

1.01
1.00

Austria

8

–

–

–

–

–

87

88

Azerbaijan

53

11

–

93

95

1.02

87

88

1.01

Bahamas

32

–

–

85

92

1.08

79

86

1.09

Bahrain

14

–

–

99

99

1.00

92

94

1.02

Bangladesh

78

59

–

92

98

1.07

57

67

1.17

Barbados

50

11

–

90

91

1.00

93

99

1.07

Belarus

16

3

–

96

96

1.00

95

96

1.01
1.00

Belgium

7

–

–

99

99

1.00

94

94

Belize

69

26

–

100

99

0.99

68

73

1.07

Benin

94

26

2

100

90

0.90

53

40

0.75

Bhutan

28

26

–

81

83

1.02

61

71

1.17

Bolivia (Plurinational State of)

71

19

–

93

92

0.99

78

78

1.00

Bosnia and Herzegovina

11

4

–

–

–

–

–

–

–

Botswana

39

–

–

89

90

1.01

–

–

–

Brazil

62

26

–

96

98

1.02

80

84

1.05

Brunei Darussalam

11

–

–

97

96

1.00

82

85

1.03

Bulgaria

39

–

–

93

93

1.00

91

89

0.97

Burkina Faso

129

52

58

78

76

0.98

29

29

1.01

158

I NDICATOR S

Indicators for monitoring ICPD goals
ADOLESCENTS AND YOUTH

COUNTRIES, TERRITORIESAND OTHER AREAS

Adolescent birthrate per 1,000 girls
aged 15-19

Child marriage
by age 18,
per cent

FGM prevalence
among girls aged
15-19, per cent

Adjusted net enrolment
rate, primary education,
per cent, 2009-2018

Gender parity
index, primaryeducation

Net enrolment rate,secondary education,
per cent, 2009-2018

Gender parity
index, secondary
education

2006-2017

2006-2017

2004-2017

male

female2009-2018

male

female2009-2018

Burundi

58

20

–

96

98

1.02

26

32

1.21

Cambodia

57

19

–

91

90

1.00

–

–

–

Cameroon, Republic of

119

31

0

99

91

0.92

50

44

0.88

Canada

11

–

–

–

–

–

99

100

1.01

Cape Verde

80

–

–

87

86

0.98

61

68

1.11

Central African Republic

229

68

18

77

60

0.79

16

10

0.61

Chad

179

67

32

71

55

0.77

–

–

–

Chile

41

–

–

93

93

1.00

86

89

1.04

China

9

–

–

–

–

–

–

–

–

China, Hong Kong SAR

3

–

–

–

–

–

93

93

1.00

China, Macao SAR

3

–

–

99

99

1.00

84

87

1.05

Colombia

75

23

–

93

94

1.01

76

82

1.07

Comoros

70

32

–

85

84

0.99

41

45

1.09

Congo, Democratic Republic of the

138

37

–

–

–

–

–

–

–

Congo, Republic of the

147

27

–

84

91

1.09

–

–

–

Costa Rica

53

21

–

97

97

1.00

81

84

1.04

Côte d’Ivoire

129

27

27

93

85

0.91

45

33

0.75

Croatia

10

–

–

96

99

1.04

89

92

1.04

Cuba

50

26

–

97

97

1.00

84

89

1.06

Curaçao

35

–

–

–

–

–

–

–

–
1.01

Cyprus

5

–

–

98

98

1.01

94

95

Czechia

12

–

–

–

–

–

90

92

1.02

Denmark

3

–

–

99

99

1.01

88

92

1.04

Djibouti

21

5

90

62

56

0.89

38

32

0.83

Dominica

–

–

–

97

99

1.02

90

97

1.08

Dominican Republic

90

36

–

88

88

1.00

62

71

1.13

Ecuador

111

–

–

97

99

1.02

87

89

1.02

Egypt

56

17

70

98

99

1.01

81

82

1.00

El Salvador

69

26

–

81

82

1.01

60

61

1.02

Equatorial Guinea

176

30

–

44

45

1.02

–

–

–

Eritrea

76

41

69

39

36

0.91

27

25

0.92

Estonia

13

–

–

93

94

1.01

93

95

1.02

Eswatini

87

5

–

76

75

0.98

32

41

1.29

Ethiopia

80

40

47

89

83

0.93

31

30

0.97

Fiji

40

–

–

98

98

1.01

79

88

1.11

Finland

6

–

–

99

99

1.00

96

96

1.01

France

5

–

–

99

99

1.01

93

94

1.01

French Guiana

87

–

–

–

–

–

–

–

–

French Polynesia

40

–

–

–

–

–

–

–

–

Gabon

91

22

–

–

–

–

–

–

–

Gambia

88

30

76

75

83

1.10

–

–

–

Georgia

44

14

–

98

98

0.99

97

99

1.02

STAT E OF WOR L D POPUL AT I ON 2 01 9

159

Indicators for monitoring ICPD goals
ADOLESCENTS AND YOUTH

COUNTRIES, TERRITORIESAND OTHER AREAS

Adolescent birthrate per 1,000 girls
aged 15-19

Child marriage
by age 18,
per cent

FGM prevalence
among girls aged
15-19, per cent

Adjusted net enrolment
rate, primary education,
per cent, 2009-2018

Gender parity
index, primaryeducation

2009-2018

Net enrolment rate,secondary education,
per cent, 2009-2018

Gender parity
index, secondary
education

2006-2017

2006-2017

2004-2017

male

femalemale

femaleGermany

8

–

–

–

–

–

–

–

2009-2018
–

Ghana

76

21

2

84

86

1.02

56

57

1.01

Greece

8

–

–

93

93

1.00

91

89

0.99

Grenada

–

–

–

96

97

1.01

80

72

0.91

Guadeloupe

–

–

–

–

–

–

–

–

–

Guam

38

–

–

–

–

–

–

–

–

Guatemala

92

30

–

87

87

1.00

48

46

0.96

Guinea

146

51

95

86

71

0.83

40

26

0.66

Guinea-Bissau

106

24

42

74

70

0.95

–

–

–

Guyana

74

30

–

95

97

1.02

81

86

1.06

Haiti

55

18

–

–

–

–

–

–

–

Honduras

103

34

–

83

84

1.02

43

48

1.14

Hungary

23

–

–

97

97

1.00

89

89

1.00

Iceland

8

–

–

100

99

1.00

89

91

1.03

India

28

27

–

97

98

1.01

61

62

1.01

Indonesia

48

14

–

95

90

0.95

76

78

1.02

Iran (Islamic Republic of)

38

17

–

–

–

–

72

73

1.00

Iraq

82

24

5

–

–

–

–

–

–

Ireland

9

–

–

100

100

1.00

97

99

1.01

Israel

10

–

–

97

98

1.01

98

100

1.02

Italy

5

–

–

99

98

1.00

96

96

1.00

Jamaica

46

8

–

–

–

–

71

77

1.09

Japan

4

–

–

98

98

1.00

99

100

1.01

Jordan

26

8

–

–

–

–

63

65

1.03

Kazakhstan

31

7

–

98

100

1.02

100

100

1.00

Kenya

96

23

11

81

85

1.04

50

47

0.94

Kiribati

49

20

–

–

–

–

–

–

–
1.01

Korea, Democratic People’s Republic of

1

–

–

97

97

1.00

90

91

Korea, Republic of

1

–

–

96

97

1.00

97

98

1.00

Kuwait

6

–

–

93

93

1.00

84

89

1.07

Kyrgyzstan

38

12

–

99

98

0.99

87

87

1.00

Lao People’s Democratic Republic

76

35

–

94

93

0.99

61

60

0.98

Latvia

18

–

–

96

97

1.01

93

95

1.02

Lebanon

–

6

–

91

86

0.94

65

65

1.00

Lesotho

94

17

–

81

83

1.03

29

45

1.53

Liberia

149

36

26d

39

36

0.93

16

14

0.88

Libya

11

–

–

–

–

–

–

–

–

Lithuania

14

–

–

100

100

1.00

98

97

1.00

Luxembourg

6

–

–

99

99

1.00

83

86

1.04

Madagascar

152

41

–

–

–

–

28

30

1.08

Malawi

136

42

–

95

99

1.04

32

31

0.96

Malaysia

12

–

–

98

99

1.00

72

78

1.08

160

I NDICATOR S

Indicators for monitoring ICPD goals
ADOLESCENTS AND YOUTH

COUNTRIES, TERRITORIESAND OTHER AREAS

Adolescent birthrate per 1,000 girls
aged 15-19

Child marriage
by age 18,
per cent

FGM prevalence
among girls aged
15-19, per cent

Adjusted net enrolment
rate, primary education,
per cent, 2009-2018

Gender parity
index, primaryeducation

Net enrolment rate,secondary education,
per cent, 2009-2018

Gender parity
index, secondary
education

2006-2017

2006-2017

2004-2017

male

female2009-2018

male

femaleMaldives

13

4

–

100

100

1.00

–

–

2009-2018
–

Mali

174

52

83

71

63

0.89

32

26

0.80

Malta

11

–

–

97

100

1.03

87

92

1.05

Martinique

20

–

–

–

–

–

–

–

–

Mauritania

71

37

63

75

78

1.05

26

25

0.97

Mauritius

24

–

–

95

97

1.02

82

88

1.08
1.04

Mexico

63

26

–

98

100

1.02

76

79

Micronesia (Federated States of)

44

–

–

83

85

1.03

–

–

–

Moldova, Republic of

27

12

–

90

90

1.00

78

78

1.00

Mongolia

27

5

–

99

98

0.99

–

–

–

Montenegro

11

5

–

97

96

0.99

89

89

1.00

Morocco

32

–

–

97

97

1.00

64

63

0.99

Mozambique

167

48

–

89

86

0.97

19

19

1.02
1.09

Myanmar

36

16

–

90

89

0.99

57

62

Namibia

82

7

–

96

100

1.04

–

–

–

Nepal

88

40

–

96

93

0.97

53

57

1.07

Netherlands

3

–

–

–

–

–

93

94

1.01

New Caledonia

22

–

–

–

–

–

–

–

–

New Zealand

16

–

–

98

99

1.01

95

97

1.02

Nicaragua

92

35

–

97

100

1.03

45

53

1.17

Niger

210

76

1

71

62

0.87

24

17

0.73

Nigeria

145

44

12

72

60

0.84

–

–

–

North Macedonia

16

7

–

92

92

1.00

–

–

–

Norway

5

–

–

100

100

1.00

95

96

1.01

Oman

14

–

–

99

99

1.00

91

91

0.99

Pakistan

44

21

–

82

71

0.86

49

40

0.81

Palestine1

48

15

–

94

94

1.00

79

87

1.10
1.07

Panama

79

26

–

88

87

0.99

67

72

Papua New Guinea

–

21

–

80

75

0.93

36

30

0.82

Paraguay

62

22

–

79

79

1.00

63

67

1.07

Peru

65

22

–

99

100

1.01

80

81

1.02

Philippines

47

15

–

95

96

1.01

60

72

1.19

Poland

12

–

–

96

96

1.00

92

93

1.01

Portugal

8

–

–

97

96

1.00

93

94

1.01

Puerto Rico

30

–

–

79

84

1.07

72

77

1.07

Qatar

10

4

–

99

98

0.99

68

85

1.25

Reunion

44

–

–

–

–

–

–

–

–

Romania

35

–

–

90

90

1.00

81

81

1.00

Russian Federation

24

–

–

97

98

1.01

94

95

1.01

Rwanda

45

7

–

94

94

1.01

25

30

1.18

Saint Kitts and Nevis

46

–

–

–

–

–

–

–

–

Saint Lucia

–

8

–

–

–

–

79

81

1.03

STAT E OF WOR L D POPUL AT I ON 2 01 9

161

Indicators for monitoring ICPD goals
ADOLESCENTS AND YOUTH

COUNTRIES, TERRITORIESAND OTHER AREAS

Adolescent birthrate per 1,000 girls
aged 15-19

Child marriage
by age 18,
per cent

FGM prevalence
among girls aged
15-19, per cent

Adjusted net enrolment
rate, primary education,
per cent, 2009-2018

Gender parity
index, primaryeducation

Net enrolment rate,secondary education,
per cent, 2009-2018

Gender parity
index, secondary
education

2006-2017

2006-2017

2004-2017

male

female2009-2018

male

female2009-2018

Saint Vincent and the Grenadines

64

–

–

99

98

0.99

91

91

0.99

Samoa

39

11

–

96

97

1.01

74

81

1.10

San Marino

0

–

–

93

93

1.00

–

–

–

São Tomé and Príncipe

92

35

–

97

97

0.99

61

68

1.11

Saudi Arabia

7

–

–

99

100

1.00

86

84

0.97

Senegal

80

31

21

71

79

1.12

35

39

1.10

Serbia

16

3

–

98

99

1.00

92

93

1.01

Seychelles

66

–

–

–

–

–

87

90

1.03

Sierra Leone

125

39

74

99

99

1.01

38

37

0.97

Singapore

3

–

–

–

–

–

100

100

1.00

Sint Maarten

–

–

–

–

–

–

–

–

–

Slovakia

24

–

–

–

–

–

84

86

1.01

Slovenia

5

–

–

97

98

1.01

95

95

1.01

Solomon Islands

78

21

–

69

70

1.01

–

–

–

Somalia

64

45

97

–

–

–

–

–

–

South Africa

71

–

–

91

92

1.01

86

84

0.98

South Sudan

155

52

–

36

28

0.76

6

4

0.70

8

–

–

98

99

1.00

95

97

1.02

Spain
Sri Lanka

20

12

–

98

96

0.98

87

90

1.03

Sudan

87

34

82

57

63

1.10

–

–

–
1.22

Suriname

58

19

–

96

100

1.04

53

65

Sweden

4

–

–

100

99

1.00

100

99

1.00

Switzerland

6

–

–

100

100

1.00

87

84

0.97

Syrian Arab Republic

54

13

–

68

67

0.98

46

45

0.99

Tajikistan

54

12

–

99

98

0.99

87

78

0.90

Tanzania, United Republic of

132

31

5

78

81

1.04

23

23

1.02

Thailand

43

23

–

98

98

1.00

77

77

1.01
1.16

Timor-Leste, Democratic Republic of

50

19

–

79

82

1.04

55

64

Togo

85

22

2

95

89

0.94

48

33

0.69

Tonga

30

6

–

95

97

1.03

74

79

1.07

Trinidad and Tobago

38

11

–

99

98

0.99

–

–

–

Tunisia

7

2

–

99

98

0.99

–

–

–

Turkey

27

15

–

95

94

0.99

86

85

0.99

Turkmenistan

28

6

–

–

–

–

–

–

–

Turks and Caicos Islands

–

–

–

–

–

–

–

–

–

Tuvalu

28

10

–

–

–

–

63

79

1.26

Uganda

140

40

1

90

92

1.03

–

–

–

Ukraine

26

9

–

92

94

1.02

86

87

1.01

United Arab Emirates

34

–

–

98

96

0.98

89

86

0.96

United Kingdom

14

–

–

100

100

1.00

98

98

1.00

United States of America

20

–

–

96

96

1.00

92

92

1.00

United States Virgin Islands

25

–

–

–

–

–

–

–

–

162

I NDICATOR S

Indicators for monitoring ICPD goals
ADOLESCENTS AND YOUTH

COUNTRIES, TERRITORIESAND OTHER AREAS

Adolescent birthrate per 1,000 girls
aged 15-19

Child marriage
by age 18,
per cent

FGM prevalence
among girls aged
15-19, per cent

Adjusted net enrolment
rate, primary education,
per cent, 2009-2018

Gender parity
index, primaryeducation

Net enrolment rate,secondary education,
per cent, 2009-2018

Gender parity
index, secondary
education

2006-2017

2006-2017

2004-2017

male

female2009-2018

male

female2009-2018

Uruguay

51

25

–

98

98

1.00

80

86

1.08

Uzbekistan

30

7

–

99

98

0.98

91

90

0.99

Vanuatu

78

21

–

86

88

1.03

48

51

1.07

Venezuela (Bolivarian Republic of)

95

–

–

86

86

1.00

67

73

1.10

Viet Nam

30

11

–

–

–

–

–

–

–

Western Sahara

–

–

–

–

–

–

–

–

–

Yemen

67

32

16

88

78

0.88

54

40

0.74

Zambia

141

31

–

87

89

1.02

–

–

–

Zimbabwe

110

32

–

84

86

1.02

44

44

1.01

NOTES
−

Data not available.

aExcludes Cook Islands, Marshall Islands, Nauru, Niue, Palau, Tokelau, and Tuvalu due todata availability.

b

Excludes Anguilla, Antigua and Barbuda, Bermuda, British Virgin Islands, Cayman Islands,
Ecuador, Grenada, Montserrat, Sint Maarten, and Saint Kitts and Nevis due to data
availability.

cIncludes Seychelles.

dPercentage of girls aged 15-19 years who are members of the Sande society. Membership in
Sande society is a proxy for FGM.

1

On 29 November 2012, the United Nations General Assembly passed Resolution 67/19, whichaccorded Palestine “non-member observer State status in the United Nations...”STAT E OF WOR L D POPUL AT I ON 2 01 9163

Demographic indicators
POPULATIONFERTILITY

LIFE EXPECTANCY

Total populationin millions

Total fertility rate,
per woman

Life expectancy
at birth, years

POPULATIONCHANGEPOPULATION COMPOSITION (BY AGE)

Averageannual rate
per cent

0-14
per cent

10-24
per cent

15-64
per cent

65 and overper cent

COUNTRIES,WORLD ANDTERRITORIESANDOTHERAREAS
AREAS
REGIONAL

1969

1994

2019

1969

1994

2019

1969

1994

2019

2010-2019

2019

2019

2019

2019

WORLD

3626

5670

7715

4.8

2.9

2.5

56

65

72

1.1

26

24

65

9

More developed regions

1001

1167

1266

2.3

1.6

1.7

71

74

80

0.3

16

17

65

19

Less developed regions

2625

4503

6448

5.9

3.2

2.6

53

63

71

1.3

27

25

65

7

Least developed countries

301

570

1050

6.8

5.6

3.9

44

52

65

2.4

39

32

57

4

112

223

373

6.9

4.5

3.3

52

64

70

2.0

34

REGIONAL DATA
Arab States

28

61

5

Asia and the Pacific

1818

3027

4030

5.9

2.8

2.1

53

64

72

1.0

24

Eastern Europe and Central Asia

154

211

247

3.6

2.4

2.0

61

67

73

0.9

23

21

67

10

b

b

b

b

25

b

67

9b

a

a

a

a

23

a

68

8a

Latin America and the Caribbean

278

474

653

5.4

3.0

2.0

59

69

76

1.1

24

East and Southern Africa

154

312

613

6.8

5.9

4.3

46

49

64

2.7

41

32

55

3

West and Central Africa

118

229

447

6.6

6.3

5.1

41

49

58

2.7

43

32

54

3

10.9

16.2

37.2

7.5

7.6

4.2

36

53

65

2.8

42

35

55

3

COUNTRIES, TERRITORIESAND OTHER AREAS
Afghanistan
Albania

2.1

3.1

2.9

5.1

2.7

1.7

67

72

79

0.0

17

21

69

14

Algeria

14.1

28.4

42.7

7.7

3.7

2.6

50

68

77

1.9

30

22

64

7

Angola

6.6

13.8

31.8

7.6

7.0

5.5

37

43

62

3.4

46

33

51

3

Antigua and Barbuda

0.1

0.1

0.1

3.8

2.2

2.0

66

72

77

1.1

23

24

69

7

Argentina

23.6

34.6

45.1

3.1

2.8

2.2

66

72

77

1.0

24

24

64

11

Armenia

2.5

3.3

2.9

3.3

2.2

1.6

70

69

75

0.2

20

19

68

12

Aruba

0.1

0.1

0.1

3.1

2.1

1.8

69

74

76

0.5

17

21

68

14

Australia1

12.6

17.9

25.1

2.8

1.8

1.8

71

78

83

1.4

19

19

65

16

Austria

7.5

7.9

8.8

2.4

1.5

1.5

70

77

82

0.5

14

15

66

20

Azerbaijan2

5.1

7.7

10.0

5.2

2.7

2.0

63

65

72

1.1

23

21

70

6

Bahamas

0.2

0.3

0.4

3.6

2.6

1.7

66

71

76

1.2

20

21

70

10

Bahrain

0.2

0.5

1.6

6.7

3.2

2.0

63

73

77

3.1

19

18

79

3

Bangladesh

63.4

116.2

168.1

6.9

3.8

2.0

48

61

73

1.1

27

28

68

5

Barbados

0.2

0.3

0.3

3.3

1.7

1.8

65

72

76

0.3

19

19

65

16

Belarus

8.9

10.2

9.4

2.3

1.5

1.7

71

69

73

0.0

17

15

67

15

Belgium

9.6

10.2

11.6

2.3

1.6

1.8

71

77

82

0.6

17

17

64

19

Belize

0.1

0.2

0.4

6.3

4.2

2.4

65

70

71

2.1

30

30

66

4

Benin

2.9

5.7

11.8

6.7

6.4

4.8

42

55

62

2.8

42

32

55

3

Bhutan

0.3

0.5

0.8

6.7

4.8

2.0

39

56

71

1.4

26

27

69

5

Bolivia (Plurinational State of)

4.4

7.4

11.4

6.3

4.6

2.8

45

57

70

1.5

31

29

62

7

Bosnia and Herzegovina

3.7

3.9

3.5

3.0

1.7

1.4

66

71

77

–0.7

14

17

68

17

Botswana

0.7

1.5

2.4

6.7

4.1

2.6

54

57

69

1.8

31

28

65

4

Brazil

92.9

159.7

212.4

5.2

2.6

1.7

59

67

76

0.8

21

23

70

9

Brunei Darussalam

0.1

0.3

0.4

5.8

2.9

1.8

67

74

78

1.4

22

23

72

5

Bulgaria

8.5

8.5

7.0

2.1

1.4

1.6

71

71

75

–0.6

15

14

64

21

Burkina Faso

5.5

9.8

20.3

6.6

6.9

5.1

39

49

62

2.9

45

33

53

2

164

I NDICATOR S

Demographic indicators

COUNTRIES, TERRITORIESAND OTHER AREAS

POPULATIONFERTILITY

LIFE EXPECTANCY

Total populationin millions

Total fertility rate,
per woman

Life expectancy
at birth, years

POPULATIONCHANGEPOPULATION COMPOSITION (BY AGE)

Averageannual rate
per cent

0-14
per cent

10-24
per cent

15-64
per cent

65 and overper cent

1969

1994

2019

1969

1994

2019

1969

1994

2019

2010-2019

2019

2019

2019

2019

Burundi

3.4

5.9

11.6

7.3

7.3

5.5

44

48

59

3.1

45

31

52

3

Cambodia

6.9

10.3

16.5

6.6

4.9

2.5

42

55

70

1.6

31

28

64

5

Cameroon, Republic of

6.4

13.1

25.3

6.2

6.1

4.5

46

50

60

2.6

42

32

55

3

Canada

21.1

29.0

37.3

2.4

1.7

1.6

72

78

83

1.0

16

17

66

18

Cape Verde

0.3

0.4

0.6

7.0

4.7

2.2

53

66

73

1.2

29

30

66

5

Central African Republic

1.8

3.3

4.8

6.0

5.7

4.6

41

47

54

0.9

42

34

54

4

Chad

3.6

6.8

15.8

6.5

7.4

5.6

41

47

54

3.2

47

34

51

3

Chile

9.4

14.1

18.3

4.2

2.4

1.8

62

75

80

0.8

20

21

68

12

China3803.6

1229.01420.1

5.9

1.7

1.6

58

70

77

0.5

18

17

71

12

China, Hong Kong SAR4

3.8

6.1

7.5

3.4

1.2

1.4

71

79

84

0.7

12

13

70

17

China, Macao SAR5

0.2

0.4

0.6

2.4

1.3

1.4

69

79

84

2.0

14

13

75

11

Colombia

21.5

36.8

49.8

5.8

2.7

1.8

61

69

75

0.9

23

24

69

8

Comoros

0.2

0.5

0.9

7.1

5.9

4.1

45

58

64

2.3

39

31

58

3

Congo, Democratic Republic of the

19.5

40.3

86.7

6.2

6.8

5.8

44

49

61

3.3

46

32

51

3

Congo, Republic of the

1.3

2.7

5.5

6.3

5.2

4.5

53

54

66

2.6

42

31

55

3

Costa Rica

1.8

3.4

5.0

4.9

2.9

1.7

66

76

80

1.1

21

23

69

10

Côte d’Ivoire

5.0

14.1

25.5

7.9

6.3

4.7

43

50

55

2.5

42

32

55

3

Croatia

4.4

4.7

4.1

2.0

1.6

1.4

68

73

78

–0.5

15

16

65

21

Cuba

8.6

10.9

11.5

4.2

1.6

1.7

69

75

80

0.2

16

17

69

16

Curaçao

0.1

0.1

0.2

3.5

2.2

2.0

69

75

79

1.1

18

18

64

17

6

Cyprus

0.6

0.8

1.2

2.7

2.2

1.3

72

77

81

0.8

17

20

69

14

Czechia

9.8

10.4

10.6

2.0

1.5

1.6

70

73

79

0.1

16

14

64

20

Denmark

4.9

5.2

5.8

2.2

1.8

1.8

73

75

81

0.4

16

18

64

20

Djibouti

0.1

0.6

1.0

6.8

5.5

2.7

48

57

63

1.6

30

30

66

4

Dominica

0.1

0.1

0.1

–

–

–

–

–

–

0.5

–

–

–

–

Dominican Republic

4.4

7.8

11.0

6.4

3.2

2.3

58

69

74

1.2

29

27

64

7

Ecuador

5.9

11.2

17.1

6.3

3.4

2.4

57

71

77

1.5

28

26

65

8

Egypt

34.2

62.5

101.2

6.3

3.9

3.1

52

66

72

2.1

33

26

62

5

El Salvador

3.6

5.5

6.4

6.3

3.7

2.0

55

67

74

0.5

27

28

65

9

Equatorial Guinea

0.3

0.5

1.4

5.8

6.0

4.4

39

50

59

4.0

37

29

60

3

Eritrea

1.8

3.1

5.3

6.7

6.0

3.9

43

52

66

2.1

41

32

55

4

Estonia

1.3

1.5

1.3

2.1

1.5

1.7

70

69

78

–0.2

17

15

63

20

Eswatini

0.4

0.9

1.4

6.9

5.0

2.9

47

58

59

1.8

37

32

60

3

Ethiopia

27.7

55.4

110.1

6.9

7.0

3.9

43

49

67

2.5

39

34

57

4

Fiji

0.5

0.8

0.9

4.7

3.3

2.4

59

66

71

0.7

28

26

65

7

7

Finland

4.6

5.1

5.6

2.0

1.8

1.8

70

76

82

0.4

17

17

62

22

France

50.5

58.0

65.5

2.6

1.7

2.0

72

78

83

0.4

18

18

62

20

French Guiana

0.0

0.1

0.3

4.8

4.0

3.2

65

73

81

2.6

32

28

62

6

French Polynesia

0.1

0.2

0.3

5.1

2.9

2.0

60

70

77

0.8

23

24

69

8

Gabon

0.6

1.1

2.1

5.0

5.1

3.6

46

61

67

2.8

36

28

60

4

Gambia

0.4

1.0

2.2

6.0

6.1

5.2

37

53

62

3.1

45

33

53

2

4.7

5.1

3.9

2.7

1.9

2.0

67

70

74

–0.9

20

18

65

15

8

Georgia

STAT E OF WOR L D POPUL AT I ON 2 01 9

165

Demographic indicators
POPULATIONFERTILITY

LIFE EXPECTANCY

Total populationin millions

Total fertility rate,
per woman

Life expectancy
at birth, years

POPULATIONCHANGEPOPULATION COMPOSITION (BY AGE)

Averageannual rate
per cent

0-14
per cent

10-24
per cent

15-64
per cent

65 and overper cent

COUNTRIES, TERRITORIESAND OTHER AREAS

1969

1994

2019

1969

1994

2019

1969

1994

2019

2010-2019

2019

2019

2019

2019

Germany

78.3

80.9

82.4

2.2

1.3

1.5

71

76

82

0.2

13

14

65

22

Ghana

8.4

16.3

30.1

7.0

5.2

3.8

49

58

64

2.3

38

31

58

3

Greece

8.6

10.7

11.1

2.6

1.4

1.3

71

78

82

–0.3

14

15

65

21

Grenada

0.1

0.1

0.1

4.7

3.3

2.0

64

69

74

0.4

26

25

66

8

Guadeloupe

0.3

0.4

0.4

5.0

2.1

1.9

64

75

82

0.0

18

21

64

19

Guam

0.1

0.1

0.2

4.5

2.9

2.3

65

73

80

0.5

24

25

66

10

Guatemala

5.5

10.2

17.6

6.7

5.2

2.8

52

65

74

2.0

34

32

61

5

Guinea

4.2

7.5

13.4

6.2

6.4

4.6

36

52

62

2.4

42

32

55

3

Guinea-Bissau

0.7

1.1

2.0

6.0

6.4

4.4

41

51

59

2.5

41

31

56

3

Guyana

0.7

0.8

0.8

5.5

3.1

2.4

62

64

67

0.6

28

29

66

6

Haiti

4.6

7.7

11.2

5.8

5.0

2.8

47

56

64

1.3

32

30

63

5

Honduras

2.6

5.6

9.6

7.3

4.7

2.4

52

68

74

1.7

30

31

65

5

Hungary

10.3

10.4

9.7

2.0

1.6

1.4

69

70

76

–0.3

14

16

66

20

Iceland

0.2

0.3

0.3

3.1

2.2

1.9

74

79

83

0.7

20

20

65

15

India

541.5

942.2

1368.7

5.6

3.7

2.3

47

60

69

1.2

27

27

67

6

Indonesia

111.8

193.9

269.5

5.5

2.8

2.3

54

65

70

1.2

27

26

68

6

Iran (Islamic Republic of)

27.8

59.7

82.8

6.5

3.5

1.6

50

68

77

1.2

24

21

70

6

Iraq

9.6

19.6

40.4

7.4

5.5

4.2

58

68

70

3.0

40

31

57

3

Ireland

2.9

3.6

4.8

3.8

1.9

2.0

71

75

82

0.5

21

19

64

15

Israel

2.8

5.2

8.6

3.8

2.9

2.9

72

78

83

1.6

28

23

60

12

Italy

53.2

57.3

59.2

2.5

1.2

1.5

71

78

84

–0.1

13

14

63

24

9

Jamaica

1.8

2.5

2.9

5.6

2.8

2.0

68

72

76

0.3

23

25

67

10

Japan

103.5

126.1

126.9

2.1

1.4

1.5

72

80

84

–0.1

13

14

59

28

Jordan

1.6

4.4

10.1

8.0

4.8

3.2

59

71

75

3.8

35

30

61

4

Kazakhstan

12.9

16.2

18.6

3.6

2.4

2.5

62

64

70

1.4

29

20

64

7

Kenya

10.9

26.5

52.2

8.1

5.5

3.7

52

55

68

2.6

40

33

58

3
4

Kiribati

0.1

0.1

0.1

5.7

4.4

3.5

54

62

67

1.8

36

29

60

Korea, Democratic People’s Republic of

14.0

21.6

25.7

4.4

2.2

1.9

59

68

72

0.5

20

22

71

9

Korea, Republic of

31.6

44.8

51.3

4.5

1.6

1.3

60

73

83

0.4

13

16

72

15

Kuwait

0.7

1.7

4.2

7.3

2.7

1.9

66

73

75

3.9

21

19

76

3

Kyrgyzstan

2.9

4.5

6.2

5.2

3.4

2.9

60

66

71

1.5

32

25

63

5

Lao People’s Democratic Republic

2.6

4.7

7.1

6.0

5.6

2.5

46

56

68

1.4

32

30

64

4

Latvia

2.4

2.5

1.9

1.9

1.5

1.6

70

68

75

–1.1

16

14

64

20

Lebanon

2.3

3.0

6.1

5.1

2.7

1.7

66

72

80

3.7

22

25

69

9

Lesotho

1.0

1.7

2.3

5.8

4.6

2.9

49

58

55

1.3

35

32

60

5

Liberia

1.4

2.0

5.0

6.7

6.2

4.4

39

49

64

2.6

41

32

56

3

Libya

2.0

4.9

6.6

8.1

3.9

2.2

55

70

72

0.7

28

25

68

5

Lithuania

3.1

3.6

2.9

2.3

1.7

1.7

71

70

75

–1.0

15

16

65

19

Luxembourg

0.3

0.4

0.6

2.1

1.7

1.6

70

76

82

1.8

16

18

69

15

Madagascar

6.4

13.1

27.0

7.3

6.0

4.0

44

54

67

2.7

40

33

57

3

Malawi

4.5

9.8

19.7

7.3

6.5

4.4

40

47

64

2.9

43

34

54

3

Malaysia10

10.5

20.0

32.5

5.2

3.4

2.0

64

72

76

1.6

24

25

69

7

Maldives

0.1

0.2

0.5

7.2

4.6

2.0

43

65

78

2.4

23

21

72

4

166

I NDICATOR S

Demographic indicators
POPULATIONFERTILITY

LIFE EXPECTANCY

Total populationin millions

Total fertility rate,
per woman

Life expectancy
at birth, years

POPULATIONCHANGEPOPULATION COMPOSITION (BY AGE)

Averageannual rate
per cent

0-14
per cent

10-24
per cent

15-64
per cent

65 and overper cent

2019

COUNTRIES, TERRITORIESAND OTHER AREAS

1969

1994

2019

1969

1994

2019

1969

1994

2019

2010-2019

2019

2019

2019

Mali

5.9

9.4

19.7

7.1

7.1

5.8

32

47

59

3.0

47

33

50

2

Malta

0.3

0.4

0.4

2.0

2.0

1.5

71

77

81

0.4

15

15

65

20

Martinique

0.3

0.4

0.4

4.8

1.9

1.9

65

76

83

–0.3

17

19

63

20

Mauritania

1.1

2.3

4.7

6.8

5.8

4.5

49

59

64

2.8

39

31

57

3

11

Mauritius

0.8

1.1

1.3

4.2

2.2

1.4

63

70

75

0.2

17

22

71

12

Mexico

50.4

92.3

132.3

6.8

3.1

2.1

61

72

78

1.3

26

26

67

7

Micronesia (Federated States of)

0.1

0.1

0.1

6.9

4.7

3.0

61

67

70

0.4

32

33

62

5

Moldova, Republic of

3.5

4.4

4.0

2.6

2.0

1.2

65

67

72

–0.1

16

17

72

12

Mongolia

1.2

2.3

3.2

7.6

2.9

2.6

55

61

70

1.7

30

22

66

4

12

Montenegro

0.5

0.6

0.6

2.8

2.0

1.6

69

74

78

0.1

18

19

66

16

Morocco

15.7

26.7

36.6

6.7

3.4

2.4

52

67

77

1.4

27

24

66

7

Mozambique

9.0

15.2

31.4

6.8

6.0

5.1

39

45

60

2.9

44

33

53

3

Myanmar

25.7

42.7

54.3

6.0

3.1

2.1

50

60

67

0.9

26

27

68

6

Namibia

0.8

1.6

2.6

6.4

4.7

3.2

52

61

66

2.2

36

31

60

4

Nepal

11.8

20.9

29.9

5.9

4.8

2.0

40

58

71

1.1

29

32

64

6

Netherlands

12.9

15.4

17.1

2.6

1.6

1.8

74

77

82

0.3

16

18

64

20

New Caledonia

0.1

0.2

0.3

5.3

2.8

2.1

62

72

78

1.3

22

22

68

10

New Zealand

2.8

3.6

4.8

3.2

2.0

2.0

71

77

82

1.0

20

20

64

16

Nicaragua

2.3

4.5

6.4

6.9

3.9

2.1

53

67

76

1.1

28

28

66

6

Niger

4.4

9.2

23.2

7.6

7.7

7.1

36

46

61

3.8

50

33

47

3

Nigeria

54.7

105.4

201.0

6.4

6.3

5.3

41

46

55

2.6

44

32

54

3

North Macedonia

1.7

2.0

2.1

3.3

2.0

1.6

66

72

76

0.1

16

18

69

14

Norway13

3.8

4.3

5.4

2.7

1.9

1.8

74

78

83

1.1

18

18

65

17

Oman

0.7

2.1

5.0

7.3

5.7

2.5

50

69

78

5.5

21

19

76

2

Pakistan

56.5

119.8

204.6

6.6

5.5

3.3

52

61

67

2.0

35

29

61

5

14

Palestine

1.1

2.5

5.2

7.9

6.4

3.8

55

69

74

2.7

39

32

58

3

Panama

1.5

2.7

4.2

5.3

2.9

2.4

65

74

79

1.6

27

25

65

8

Papua New Guinea

2.5

4.8

8.6

6.2

4.7

3.5

48

60

66

2.1

35

31

61

4

Paraguay

2.4

4.7

7.0

5.9

4.2

2.4

65

69

73

1.3

29

28

64

7

Peru

13.0

23.6

32.9

6.5

3.4

2.3

53

68

76

1.3

27

26

66

8

Philippines

34.8

68.2

108.1

6.4

4.1

2.8

61

66

70

1.6

31

29

64

5

Poland

32.4

38.4

38.0

2.3

1.8

1.3

70

72

78

–0.1

15

15

67

18

Portugal

8.7

10.1

10.3

3.0

1.5

1.2

67

75

82

–0.4

13

15

65

22

Puerto Rico

2.7

3.7

3.7

3.2

2.1

1.5

71

74

81

–0.2

17

21

67

16

Qatar

0.1

0.5

2.7

6.9

3.6

1.8

68

76

79

4.8

14

18

84

2

Reunion

0.5

0.7

0.9

5.1

2.4

2.2

62

74

81

0.8

23

23

65

12

Romania

20.3

23.1

19.5

2.8

1.4

1.6

68

70

76

–0.5

15

16

66

19

Russian Federation

129.5

148.4

143.9

2.0

1.4

1.8

69

66

71

0.1

18

15

67

15

3.6

6.0

12.8

8.2

6.3

3.7

44

29

68

2.5

39

32

57

3

RwandaSaint Kitts and Nevis

0.0

0.0

0.1

–

–

–

–

–

–

1.0

–

–

–

–

Saint Lucia

0.1

0.1

0.2

6.2

3.0

1.4

62

71

76

0.5

18

23

72

10

Saint Vincent and the Grenadines

0.1

0.1

0.1

6.2

2.8

1.9

65

71

74

0.1

23

25

69

8

STAT E OF WOR L D POPUL AT I ON 2 01 9

167

Demographic indicators
POPULATIONFERTILITY

LIFE EXPECTANCY

Total populationin millions

Total fertility rate,
per woman

Life expectancy
at birth, years

POPULATIONCHANGEPOPULATION COMPOSITION (BY AGE)

Averageannual rate
per cent

0-14
per cent

10-24
per cent

15-64
per cent

65 and overper cent

2019

COUNTRIES, TERRITORIESAND OTHER AREAS

1969

1994

2019

1969

1994

2019

1969

1994

2019

2010-2019

2019

2019

2019

Samoa

0.1

0.2

0.2

7.3

4.8

3.8

54

67

76

0.7

36

32

58

6

San Marino

0.0

0.0

0.0

–

–

–

–

–

–

0.9

–

–

–

–

São Tomé and Príncipe

0.1

0.1

0.2

6.4

5.6

4.3

55

62

67

2.2

42

33

55

3

Saudi Arabia

5.6

18.3

34.1

7.3

5.2

2.4

52

71

75

2.4

25

21

72

4

Senegal

4.1

8.5

16.7

7.3

6.1

4.6

39

57

68

2.9

43

32

54

3

Serbia15

8.1

9.9

8.7

2.4

1.9

1.6

67

72

76

–0.4

16

18

65

18

Seychelles

0.1

0.1

0.1

5.9

2.4

2.2

65

71

74

0.5

22

19

68

9

Sierra Leone

2.6

4.3

7.9

6.5

6.6

4.2

34

36

53

2.2

41

33

56

3

Singapore

2.0

3.4

5.9

3.4

1.7

1.3

68

77

84

1.6

15

17

71

14

Sint Maarten

0.0

0.0

0.0

–

–

–

–

–

–

2.4

–

–

–

–

Slovakia

4.5

5.4

5.5

2.5

1.7

1.5

70

72

77

0.1

16

16

68

16

Slovenia

1.7

2.0

2.1

2.2

1.3

1.7

69

74

81

0.2

15

14

65

20

Solomon Islands

0.2

0.3

0.6

6.8

5.3

3.7

54

59

72

2.1

38

32

58

4

Somalia

3.4

7.6

15.6

7.2

7.6

6.0

41

46

58

2.9

46

33

51

3

South Africa

22.2

41.2

58.1

5.7

3.2

2.4

55

62

64

1.3

29

27

66

6

South Sudan

3.6

5.4

13.3

6.9

6.6

4.6

35

46

58

3.1

41

32

55

3

Spain16

33.6

39.8

46.4

2.9

1.2

1.4

72

78

84

–0.1

14

15

66

20

Sri Lanka

12.2

18.1

21.0

4.5

2.3

2.0

64

69

76

0.4

23

23

66

11

Sudan

10.0

23.3

42.5

6.9

5.9

4.3

52

56

65

2.4

40

33

56

4

Suriname

0.4

0.4

0.6

5.8

3.1

2.3

63

68

72

1.0

26

26

67

7

Sweden

8.0

8.8

10.1

2.1

1.9

1.9

74

79

83

0.8

18

17

62

20

Switzerland

6.1

7.0

8.6

2.2

1.5

1.6

73

78

84

1.1

15

15

66

19

Syrian Arab Republic

6.1

13.9

18.5

7.6

4.6

2.8

58

72

73

–1.4

35

35

60

5

Tajikistan

2.8

5.7

9.3

7.0

4.7

3.2

60

63

72

2.2

35

28

61

4

Tanzania, United Republic of17

13.2

29.1

60.9

6.8

5.9

4.8

46

49

67

3.1

44

32

52

3

Thailand

35.8

58.9

69.3

5.8

1.9

1.4

59

70

76

0.3

17

19

71

12

Timor-Leste, Democratic Republic of

0.6

0.9

1.4

6.0

6.1

5.2

39

52

70

2.2

43

35

53

4

Togo

2.0

4.2

8.2

7.0

5.9

4.3

46

55

61

2.6

41

32

56

3

Tonga

0.1

0.1

0.1

6.2

4.5

3.5

65

70

73

0.6

35

33

59

6

Trinidad and Tobago

0.9

1.3

1.4

3.7

2.0

1.7

65

68

71

0.4

20

19

69

11

Tunisia

5.0

9.0

11.8

6.8

2.7

2.1

50

71

76

1.1

24

21

67

9

Turkey

34.1

57.6

83.0

5.7

2.8

2.0

52

66

77

1.5

24

24

67

9

Turkmenistan

2.1

4.1

5.9

6.5

3.7

2.7

58

63

68

1.7

31

25

65

5

Turks and Caicos Islands

0.0

0.0

0.0

–

–

–

–

–

–

1.8

–

–

–

–

Tuvalu

0.0

0.0

0.0

–

–

–

–

–

–

0.9

–

–

–

–

Uganda

9.2

19.9

45.7

7.1

7.0

5.3

49

44

61

3.3

47

34

51

2
17

18

46.7

51.1

43.8

2.0

1.5

1.6

71

68

72

–0.5

16

15

67

United Arab Emirates

0.2

2.3

9.7

6.7

3.6

1.7

61

73

78

1.8

14

16

85

1

United Kingdom

55.4

57.8

67.0

2.4

1.8

1.9

72

77

82

0.6

18

17

63

19

United States of America

207.7

262.7

329.1

2.4

2.0

1.9

71

76

80

0.7

19

20

65

16

United States Virgin Islands

0.1

0.1

0.1

5.3

2.6

2.2

69

75

80

–0.1

20

20

60

20

Uruguay

2.8

3.2

3.5

2.9

2.4

2.0

69

73

78

0.3

21

22

64

15

Ukraine168

I NDICATOR S

Demographic indicators
POPULATIONFERTILITY

LIFE EXPECTANCY

Total populationin millions

Total fertility rate,
per woman

Life expectancy
at birth, years

POPULATIONCHANGEPOPULATION COMPOSITION (BY AGE)

Averageannual rate
per cent

0-14
per cent

10-24
per cent

15-64
per cent

65 and overper cent

2019

COUNTRIES, TERRITORIESAND OTHER AREAS

1969

1994

2019

1969

1994

2019

1969

1994

2019

2010-2019

2019

2019

2019

Uzbekistan

11.7

22.4

32.8

6.4

3.7

2.2

62

66

72

1.5

28

25

67

5

Vanuatu

0.1

0.2

0.3

6.3

4.8

3.2

52

65

73

2.2

36

29

60

5

Venezuela (Bolivarian Republic of)

11.2

21.7

32.8

5.6

3.1

2.2

64

71

75

1.4

27

26

66

7

Viet Nam

42.3

73.9

97.4

6.5

2.9

1.9

60

72

77

1.1

23

21

69

8

Western Sahara

0.1

0.2

0.6

6.6

3.8

2.4

42

60

70

2.1

27

25

69

3

Yemen

6.1

14.7

29.6

7.8

7.8

3.7

40

59

66

2.5

39

33

58

3

Zambia

4.0

8.9

18.1

7.3

6.2

4.8

49

43

63

3.0

44

34

53

2

Zimbabwe

5.0

11.1

17.3

7.4

4.6

3.5

55

52

62

2.3

41

32

56

3

NOTES
−

Data not available.

8 Includes Abkhazia and South Ossetia.

aExcludes Cook Islands, Marshall Islands, Nauru, Niue, Palau, Tokelau, and Tuvalu due to data
availability.

9 Includes Saint-Barthélemy and Saint-Martin (French part).

b

Excludes Anguilla, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Montserrat,
Saint Kitts and Nevis, Sint Maarten, and Turks and Caicos Islands due to data availability.

1

Includes Christmas Island, Cocos (Keeling) Islands and Norfolk Island.

2

Includes Nagorno-Karabakh.

3

For statistical purposes, the data for China do not include Hong Kong and Macao, Special
Administrative Regions (SAR) of China, and Taiwan Province of China.

4

As of 1 July 1997, Hong Kong became a Special Administrative Region (SAR) of China.

5

As of 20 December 1999, Macao became a Special Administrative Region (SAR) of China.

6

Refers to the whole country.

7

Includes Åland Islands.

10 Includes Sabah and Sarawak.
11 Includes Agalega, Rodrigues and Saint Brandon.
12 Includes Transnistria.
13 Includes Svalbard and Jan Mayen Islands.
14 Includes East Jerusalem. On 29 November 2012, the United Nations General Assembly
passed Resolution 67/19, which accorded Palestine “non-member observer State status
in the United Nations...”15 Includes Kosovo.
16 Includes Canary Islands, Ceuta and Melilla.
17 Includes Zanzibar.
18 Includes Crimea.

STAT E OF WOR L D POPUL AT I ON 2 01 9

169

Technical notes for indicators
The statistical tables in State of World Population 2019 include
indicators that track progress toward the goals of the
Framework of Actions for the follow-up to the Programmeof Action of the International Conference on Population andDevelopment (ICPD), and the Sustainable Development
Goals (SDGs) in the areas of maternal health, access to
education, reproductive and sexual health. In addition, thesetables include a variety of demographic indicators. The
statistical tables support UNFPA’s focus on progress andresults towards delivering a world where every pregnancy
is wanted, every birth is safe, and every young person's
potential is fulfilled.

Unmet need for family planning, women aged 15-49 (2019).
Source: United Nations Population Division. Percentage ofmarried or in-union women aged 15 to 49 who want to stop or
delay childbearing but are not using a method of contraception.

Different national authorities and international organizations
may employ different methodologies in gathering, extrapolatingor analyzing data. To facilitate the international comparability of
data, UNFPA relies on the standard methodologies employedby the main sources of data. In some instances, therefore, thedata in these tables differ from those generated by national
authorities. Data presented in the tables are not comparable tothe data in previous State of the World Population reports due toregional classifications updates, methodological updates, andrevisions of time series data.

Proportion of demand satisfied with modern methods,
women aged 15-49 (1969, 1994, 2019). Source: United
Nations Population Division. Percentage of total demand forfamily planning among married or in-union women aged 15
to 49 that is satisfied by the use of modern contraception.
Contraceptive prevalence or modern contraceptive prevalence
divided by total demand for family planning. Total demand forfamily planning is the sum of contraceptive prevalence andunmet need for family planning.

The statistical tables draw on nationally representative
household surveys such as Demographic and Health Surveys(DHS) and Multiple Indicator Cluster Surveys (MICS),
United Nations organizations estimates, and inter-agency
estimates. They also include the latest population estimatesand projections from World Population Prospects: The 2017
revision, and Model-based Estimates and Projections of Family
Planning Indicators 2018 (United Nations Department of
Economic and Social Affairs, Population Division). Data areaccompanied by definitions, sources, and notes. The statistical
tables in State of World Population 2019 generally reflect
information available as of January 2019.

Indicators for monitoring ICPD goals
Sexual and Reproductive Health and Rights
Contraceptive prevalence rate, women aged 15-49, any
method (2019). Source: United Nations Population Division.
Model-based estimates are based on data that are derived fromsample survey reports. Survey data estimate the proportionof married women (including women in consensual unions)currently using, respectively, any method or modern methodsof contraception. Modern or clinic and supply methods
include male and female sterilization, IUD, the pill, injectables,
hormonal implants, condoms and female barrier methods.
Contraceptive prevalence rate, women aged 15-49,
modern method (1969, 1994, 2019). Source: United Nations
Population Division. Model-based estimates are based ondata that are derived from sample survey reports. Survey
data estimate the proportion of married women (including
women in consensual unions) currently using, respectively,
any method or modern methods of contraception. Modern
or clinic and supply methods include male and female
sterilization, IUD, the pill, injectables, hormonal implants,
condoms and female barrier methods.

170

T ECHNICA L N OT E S

Proportion of demand satisfied, women aged 15-49 (2019).
Source: United Nations Population Division. Percentage of total
demand for family planning among married or in-union women
aged 15 to 49 that is satisfied. Contraceptive prevalence ormodern contraceptive prevalence divided by total demand forfamily planning. Total demand for family planning is the sum ofcontraceptive prevalence and unmet need for family planning.

Maternal mortality ratio (MMR), deaths per 100,000 live
births (1994 and 2015) and Range of MMR uncertainty(UI 80%), Lower and upper estimates (2015). Source: United
Nations Maternal Mortality Estimation Inter-agency Group(WHO, UNICEF, UNFPA, The World Bank and the United
Nations Population Division). This indicator presents the numberof deaths of women from pregnancy-related causes per
100,000 live births. The estimates are produced by theMaternal Mortality Estimation Inter-agency Group (MMEIG)
using data from vital registration systems, household surveys
and population censuses. UNFPA, WHO, the World Bank,
UNICEF, and the United Nations Population Division are
members of the MMEIG. Estimates and methodologies
are reviewed regularly by MMEIG and other agencies andacademic institutions and are revised where necessary, as
part of the ongoing process of improving maternal mortality
data. Estimates should not be compared with previous
inter-agency estimates.
Births attended by skilled health personnel, per cent (2017).
Source: Joint global database on skilled attendance at birth,
2017, United Nations Children's Fund (UNICEF) and World
Health Organisation (WHO). Regional aggregates calculated
by UNFPA based on data from the joint global database.
Percentage of births attended by skilled health personnel(doctors, nurses or midwives) is the percentage of deliveries
attended by health personnel trained in providing life-saving
obstetric care, including giving the necessary supervision, care
and advice to women during pregnancy, labour and the postpartum period; conducting deliveries on their own; and caring
for newborns. Traditional birth attendants, even if they receive"a short training course, are not included.
The United Nations Population Division produces a systematicand comprehensive set of annual, model-based estimates,and projections are provided for a range of family planning
indicators for a 60-year time period. Indicators includecontraceptive prevalence, unmet need for family planning,
total demand for family planning and the percentage ofdemand for family planning that is satisfied among married orin-union women for the period from 1970 to 2030. A Bayesianhierarchical model combined with country-specific timetrends was used to generate the estimates, projections anduncertainty assessments. The model advances prior work andaccounts for differences by data source, sample population,and contraceptive methods included in measures of prevalence.
More information on family planning model-based estimates,
methodology and updates can be found at http://www.un.org/
en/development/desa/population/theme/family-planning/cp_
model.shtml. The estimates are based on the country-specificdata compiled in World Contraceptive Use 2018.
Decision making on sexual and reproductive health andreproductive rights, per cent (2014). Source: UNFPA.
Percentage of women aged 15-49 years who are married (orin union), who make their own decisions on all three areas —sexual intercourse with their partner, use of contraception,and their healthcare.

Indicators for monitoring ICPD Goals:
Adolescents and YouthAdolescent birth rate per 1,000 girls aged 15-19 (2018)
Source: SDG global database.The adolescent birth rate
represents the risk of childbearing among adolescent women
15 to 19 years of age. For civil registration, rates are subject
to limitations which depend on the completeness of birth
registration, the treatment of infants born alive but dead before
registration or within the first 24 hours of life, the quality of
the reported information relating to age of the mother, andthe inclusion of births from previous periods. The population
estimates may suffer from limitations connected to age
misreporting and coverage. For survey and census data,
both the numerator and denominator come from the same
population. The main limitations concern age misreporting,birth omissions, misreporting the date of birth of the child,and sampling variability in the case of surveys.
Child marriage by age 18, per cent (2017). Source: SDG global
database. Regional aggregates calculated by UNFPA based ondata from SDG global database. Proportion of women aged
20-24 years who were married or in a union before age 18.
FGM prevalence among girls aged 15-19, per cent (2017).
Source: UNFPA. Proportion of girls aged 15-19 years who haveundergone female genital mutilation.
Adjusted net enrolment rate, primary education, percent (2017). Source: UNESCO Institute for Statistics (UIS).
Percentage of children of the official primary age group who areenrolled in primary or secondary education.
Gender parity index, primary education (2017). Source:
UNESCO Institute for Statistics (UIS). Ratio of female to malevalues of adjusted primary school net enrolment ratio.

Net enrolment rate, secondary education, per cent, (2017).
Source: UNESCO Institute for Statistics (UIS). Percentage ofchildren of the official secondary age group who are enrolled
in secondary education.
Gender parity index, secondary education (2017).
Source: UNESCO Institute for Statistics (UIS). Ratio of female
to male values of secondary school net enrolment ratio.

Demographic Indicators
Population
Total population in millions (1969, 1994, 2019).
Source: United Nations Population Division. Regional
aggregates calculated by UNFPA based on data from
United Nations Population Division. Estimated size ofnational populations at mid-year.

Fertility
Total fertility rate, per woman (1969, 1994, 2019).
Source: United Nations Population Division. Regional
aggregates calculated by UNFPA based on data from United
Nations Population Division. Number of children who would beborn per woman if she lived to the end of her childbearing years
and bore children at each age in accordance with prevailingage-specific fertility rates.

Life Expectancy
Life expectancy at birth, years (1969, 1994, 2019).
Source: United Nations Population Division. Regional
aggregates calculated by UNFPA based on data from United
Nations Population Division. Number of years newborn children
would live if subject to the mortality risks prevailing for the
cross section of population at the time of their birth.

Population Change
Average annual rate of population change, per cent(2010-2019). Source: UNFPA calculation based on data from
United Nations Population Division. Average exponential rateof growth of the population over a given period, based on a
medium variant projection.		

Population Composition
Population aged 0-14, per cent (2019). Source: UNFPA
calculation based on data from United Nations Population
Division. Proportion of the population between age 0 and age 14.
Population aged 10-24, per cent (2019). Source: UNFPA
calculation based on data from United Nations Population Division.
Proportion of the population between age 10 and age 24.
Population aged 15-64, per cent (2019). Source: UNFPA
calculation based on data from United Nations Population Division.
Proportion of the population between age 15 and age 64.
Population aged 65 and older, per cent (2019). Source:
UNFPA calculation based on data from United Nations
Population Division. Proportion of the population aged
65 and older.

STAT E OF WOR L D POPUL AT I ON 2 01 9

171

Regional classifications
UNFPA averages presented at the end of the statistical tables are calculated using data from countries and areas as classified below.
Arab States Region
Algeria; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; Morocco;
Oman; Palestine; Somalia; Sudan; Syrian Arab Republic; Tunisia;
Yemen
Asia and Pacific Region
Afghanistan; Bangladesh; Bhutan; Cambodia; China; Cook
Islands; Fiji; India; Indonesia; Iran (Islamic Republic of); Kiribati;
Korea, Democratic People's Republic of; Lao People's Democratic
Republic; Malaysia; Maldives; Marshall Islands; Micronesia(Federated States of); Mongolia; Myanmar; Nauru; Nepal; Niue;
Pakistan; Palau; Papua New Guinea; Philippines; Samoa; Solomon
Islands; Sri Lanka; Thailand; Timor-Leste, Democratic Republic of;Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam
Eastern Europe and Central Asia Region
Albania; Armenia; Azerbaijan; Belarus; Bosnia and Herzegovina;
Georgia; Kazakhstan; Kyrgyzstan; Moldova, North Macedonia,
Republic of; Serbia; Tajikistan; Turkey; Turkmenistan; Ukraine,
Uzbekistan.
East and Southern Africa Region
Angola; Botswana; Burundi; Comoros; Congo, Democratic
Republic of the; Eritrea; Eswatini; Ethiopia; Kenya; Lesotho;
Madagascar; Malawi; Mauritius; Mozambique; Namibia; Rwanda;
South Africa; South Sudan; Tanzania, United Republic of; Uganda;
Zambia; Zimbabwe
Latin American and the Caribbean Region
Anguilla; Antigua and Barbuda; Argentina; Aruba; Bahamas;
Barbados; Belize; Bermuda; Bolivia (Plurinational State of);Brazil; British Virgin Islands; Cayman Islands; Chile; Colombia;
Costa Rica; Cuba; Curaçao; Dominica; Dominican Republic;
Ecuador; El Salvador; Grenada; Guatemala; Guyana; Haiti;
Honduras; Jamaica; Mexico; Montserrat; Nicaragua; Panama;Paraguay; Peru; Saint Kitts and Nevis; Saint Lucia; Saint Vincent
and the Grenadines; Sint Maarten; Suriname; Trinidad andTobago; Turks and Caicos Islands; Uruguay; Venezuela(Bolivarian Republic of)172

REGI ONAL CLA SS I F I CAT I O N SWest and Central Africa Region
Benin; Burkina Faso; Cameroon, Republic of; Cape Verde; Central
African Republic; Chad; Congo, Republic of the; Côte d'Ivoire;
Equatorial Guinea; Gabon; Gambia; Ghana; Guinea; GuineaBissau; Liberia; Mali; Mauritania; Niger; Nigeria; São Tomé and
Príncipe; Senegal; Sierra Leone; Togo
More developed regions comprise United Nations Population
Division regions Europe, Northern America, Australia/New
Zealand and Japan.
Less developed regions comprise all United Nations Population
Division regions of Africa, Asia (except Japan), Latin America andthe Caribbean plus Melanesia, Micronesia and Polynesia.
The least developed countries, as defined by the United
Nations General Assembly in its resolutions (59/209, 59/210,
60/33, 62/97, 64/L.55, 67/L.43, 64/295 and 68/18) included
47 countries (as of March 2018): 33 in Africa, 9 in Asia, 4in Oceania and one in Latin America and the Caribbean —Afghanistan, Angola, Bangladesh, Benin, Bhutan, Burkina Faso,
Burundi, Cambodia, Central African Republic, Chad, Comoros,
Democratic Republic of the Congo, Djibouti, Eritrea, Ethiopia,
Gambia, Guinea, Guinea-Bissau, Haiti, Kiribati, Lao People's
Democratic Republic, Lesotho, Liberia, Madagascar, Malawi,
Mali, Mauritania, Mozambique, Myanmar, Nepal, Niger, Rwanda,
São Tomé and Príncipe, Senegal, Sierra Leone, Solomon Islands,
Somalia, South Sudan, Sudan, Timor-Leste, Togo, Tuvalu, Uganda,
United Republic of Tanzania, Vanuatu, Yemen and Zambia. These
countries are also included in the less developed regions.

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Ensuringles
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REF ERE NC E S

Ensuring rights and choices for all since 1969
United Nations Population Fund
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New York, NY 10158+1 (212) 297-5000
www.unfpa.org@UNFPAISSN 1020-5195
ISBN 978-0-89714-029-4

Sales No. E.19.III.H.1
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