state of world population 2024
Interwoven Lives, Threads of Hope

INTERWOVENLIVES,THREADSOF HOPE
Ending inequalities insexual and reproductive
health and rights

swp2024-english-240327.indd 1

3/28/24 11:12 AM        
      ­ 
 
 
       
  

 
            
  

                
   

    
  
    
 
       
 
      
    
 ­     
 


          

      
              
                   
                                                           
       
  ¡ 
                     
                    ¢ ¡       
  ¢          
  ¡    
   
£¤       
£¤    £¤ £ ¤     
                   
        
 
           ¢       
         ¥      
 
      

Ensuring rights and choices for all

swp2024-english-240327.indd 2

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INTERWOVEN LIVES,THREADS OF HOPE
Ending inequalities in sexual andreproductive health and rights

swp2024-english-240327.indd 1

3/28/24 11:12 AM

CONTENTS   CHAPTER 1

CHAPTER 2

A work inprogress

Unravellinginequality

  


           

 
       

     
       

      ­             

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CHAPTER 3

CHAPTER 4

CHAPTER 5

Counting
every stitch

Women arethe thread



Weaving acollective
future          
      

  

             
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Thirty years ago, governments aroundthe world agreed that reproductive healthand rights are foundation stones ofglobal development – a groundbreaking
consensus that paved the way for decadesof progress. Since then, the global rate ofunintended pregnancies has fallen by nearly
20 per cent globally. The number of womenusing modern contraceptive methods has
doubled. Today at least 162 countries haveadopted laws against domestic violence,and maternal deaths have decreased by
34 per cent since 2000.
Yet that progress has not been fast enough,nor far-reaching enough. Gender-based
violence remains rampant in practically every
country and community. There has been zero
reduction in maternal mortality since 2016,
and in an alarming number of countries therates are rising. Nearly half of women still areunable to make decisions about their own
bodies — unable to exercise their sexual andreproductive health and rights.
One important reason is inequality. New
evidence in this report shows that although
women across socioeconomic classes andethnicities say barriers to health care have4

come down over time, the women mostmarginalized have experienced the least
improvement. In other words, while theworld has focused on serving the easiest
to reach, we have neglected to confront
the inequalities and disparities within oursystems and societies, which has allowed
gaps to widen into chasms.
Everywhere, people seeking essential sexualand reproductive health care are forced tonavigate overlapping hurdles because of
their gender, economic status, ethnicity,
sexual orientation, disability and more. In
the few places where data are collected,
women of African descent are found to be
more vulnerable to obstetric mistreatment
and negative maternal health outcomes.
Indigenous women are often denied
culturally appropriate maternal health care,and their own childbirth practices may
be criminalized, resulting in significantly
higher risk of death in pregnancy andchildbirth. Gender-unequal norms remain
embedded in health-care infrastructure,including persistent underinvestment in theworld’s largely female midwifery workforce.
Women and girls with disabilities face up
to 10 times more gender-based violence

Foreword

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3/28/24 11:13 AMwhile also facing higher barriers to sexualand reproductive information and care.
LGBTQIA+ people face serious healthdisparities in addition to – and as a resultof – discrimination and stigma.
The path forward to fulfill the Cairo
International Conference on Population andDevelopment promise of universal sexualand reproductive health and rights is clear:
To achieve it we must root out inequalities
from our health systems and policies andfocus as a priority on those women andyoung people who are most marginalized
and excluded.
We need comprehensive, universal andinclusive health care grounded in humanrights and evidence of what works. This work
is vitally important, it is just, and it is possible.
This report contains many examples ofprogrammes and efforts that have expanded
access to, and uptake of, quality care, usuallywith interventions tailored by and for thosemost in need. To accelerate success, we will
require more and better data, disaggregatedto understand exactly who is being left
behind, and collected with their input andsafety assured.

A diverse cross-section of people, fromfeminists to indigenous groups to climate
and youth activists, are already pointing theway forward towards a fairer, shared future.
In the end, ensuring equitable progress will
benefit all of society. That is important in its
own right, and the dividends of achieving amore just and gender-equal world could also
add trillions of dollars to the global economy.
The fabric of humanity is rich and beautiful,a tapestry composed of 8 billion threads
and counting, each one of us unique. Our
resilience comes not from any individual
strand but emanates from the collective,
interwoven whole. That is our strength, and
it is how we will proceed and succeed —by working together.
Dr. Natalia Kanem
Executive Director
United Nations Population FundS TAT E O F W O R L D P O P U L AT I O N 2024

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STATE OF WORLD POP ULA TION 2024

CHAPTER 1

CH AP T ER 1

A work in

7

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3/28/24 11:13 AMA safe birth. A choice of contraceptives.
Protection from gender-based violence. Morepeople than ever before have realized theseessential, life-sustaining rights. But the numberof people denied these rights has not yet reachedzero – as it can and as it must.
Overall, people today live longer, healthier lives.
Still, millions remain far behind on the trajectoryof progress, trapped by multiple, compounding
forms of marginalization and discrimination.
In a world of tremendous wealth and provensolutions in sexual and reproductive healthcare, such disparity suggests a lack of will, not a
shortfall of ideas or resources. This is importantto keep in mind because it means that much
faster progress in ending marginalization anddiscrimination is not just desirable but possible,
starting right now.
In 2024, the world marks the thirtiethanniversary of the 1994 International
Conference on Population and Development(ICPD) in Cairo. That conference produced awatershed global agreement putting people at thecentre of development, one that committed torealizing better health, rights and choices for all.
It affirmed a vision of human potential that has
inspired significant progress ever since, echoed
and amplified by the global 2030 Agenda for
Sustainable Development agreed in 2015.
Yet the ICPD agenda remains only partiallyrealized, for the most marginalized people most ofall. Disparities cut through every society, depriving
some human beings of fundamental sexual andreproductive health and rights. Differences in
power and opportunity related to gender, race andethnicity, among many other factors, both alone
and in combination, still largely constrain people’s

8choices and access. These dynamics manifest whena woman with a disability is refused sexual healthinformation or when a girl in an impoverishedvillage is married as a child. They arise whena pregnant woman or person from an ethnic
minority encounters abusive practices that gounquestioned in health systems.
Moving faster to bring the promise of ICPD
alive for people who have been pushed behind
is one of the world’s most urgent priorities. It’sa priority because, for each individual, bodily
autonomy – the power and agency to makechoices over one’s body and future, without
violence or coercion (UNFPA, 2021) – depends
on realizing sexual and reproductive health andrights. This determines the gains individuals
can experience across their life course, in healthbut also in education, employment and politicalparticipation. In turn, peaceful, resilient andjust societies depend on healthy and empowered
people, without exclusions.
A strong foundation is in place to realize
ICPD commitments for everyone. The world’s
understanding of how to dismantle remaining
barriers and types of discrimination is greaterthan ever before. The international community
has agreed for decades that people-centred
development requires universal access to quality
sexual and reproductive health care, and it ismoving ever closer to the holistic goals of the
reproductive justice movement (McGovern
and others, 2022). This report argues thatthe thirtieth anniversary of the ICPD is an
opportunity to pivot health and social systems
towards providing services that empower all
people, respect their diversity, uphold theirdignity, and support them to realize their rights
and bodily autonomy. It also calls for renewed

CHAPTER 1: A work in progress

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The opportunity to mobilize support for gender equality
and reproductive rights is at hand.

commitments to unwind the disparities
and inequities that still divide societies.
These inequities create and reinforce
systemic, structural barriers that chronicallymarginalize women and other groups in nearly
every aspect of life, from labour markets to
education to political participation. Now is
the moment to take decisive action towards
dismantling these barriers.
Political and social polarization, often linked
to economic disparities, is driving insecurity
around the world (United Nations, 2018),
with reproductive rights issues – including
comprehensive sexuality education,
LGBTQIA+ rights, access to contraception,abortion and gender equality – increasingly
caught in the crossfire (Kanem, 2023).
Yet reducing inequalities in sexual andreproductive health and rights could help
lessen economic disparities (UNFPA, 2017),
thereby contributing to stability, preventing
conflict (Nyård, 2018) and accelerating
development. And in many ways, theopportunity to mobilize support for genderequality and reproductive rights is at hand:This year could herald the largest cumulative
act of participatory democracy in history,
with more than 50 countries holding major
elections that will affect the fates of billions
of people (Harbath, 2023; IFES, n.d.) –among them billions of women and girls, andcountless marginalized communities.

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Progress – but not for all
Since the ICPD, remarkable progress has been
made in core areas of sexual and reproductive
health, driven by social mobilization, leadership,partnership and the commitment of people
from remote health service delivery points tothe highest echelons of government, businessand philanthropy. The relentless advocacy of
civil society and grass-roots movements has been
instrumental in securing these impressive gains(see timeline on pages 34–39).
Between 2000 and 2020, global maternalmortality declined by 34 per cent (WHO andothers, 2023), a success story that can be credited
largely to better access to skilled and emergency
obstetric care. From 1990 to 2021, the numberof women using modern contraception doubled(UN DESA, 2022). There has been a 19 per centdecline in the unintended pregnancy rate
between 1990–1994 and 2015–2019 (Bearak
and others, 2018). Births among girls aged 15
to 19 years have fallen by around one third
since 2000 (UNFPA, 2023). HIV infection
rates have dropped significantly. The numberof new infections in 2021 was almost one third
fewer than in 2010 (United Nations, 2023). The
proportion of girls subjected to female genital
mutilation has decreased significantly as well,
due to shifting attitudes towards the practice(UNICEF, 2022).
As women’s status has increased – evidenced,
for example, by slow but steady gains inleadership roles (United Nations, 2023) – so
has recognition of the importance of bodily
autonomy as a human right (OHCHR, 2017).
With the 2015 adoption of the Sustainable
Development Goals (SDGs), the international

10

community sought, through indicator 5.6.1,
to measure women’s ability to exercise bodily
autonomy, a groundbreaking global affirmationthat bodily autonomy is a human rights
imperative. Governments around the world
have also sought to protect women and girls
through legislation: A historic 162 countries
have passed laws against domestic violence(World Bank, n.d.). As a further advancementof bodily autonomy, the world is increasingly
rejecting the criminalization of LGBTQIA+
sexuality. At the start of the AIDS pandemic,
most countries criminalized same-sex sexuality,
while today two thirds of countries do not – andthis progress may be accelerating, with morecountries eliminating punitive laws in 2022
than in any single year in the past 25 years(HIV Policy Lab and others, 2023).
Other hopeful signs come from new modelsof health care backed by sound evidence
and recognition of human rights. These arereaching more people, and are more responsive
to diverse contexts and human needs. For
example, self-care models of health care havebeen endorsed by UNFPA, the World HealthOrganization (WHO) and other public healthorganizations, following rapid advancements
in new technologies that enable users topromote and maintain their own health, andcope with illness and disability, without thedirect intervention of a health worker. Suchdevelopments could greatly expand access tosexual and reproductive health (UNFPA, 2024).
Also promising is the growing acknowledgementthat health care delivered by skilled midwives –whose ancient profession has long been sidelined
within modern medicine (see Chapter 2) – isboth life-saving and cost-saving (UNFPA andothers, 2021).

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Gender equality is increasingly understood as
one of the smartest development investments,
generating enormous social and economic gains(UNFPA, 2023a), while the economic returns
on investment in sexual and reproductive healthare compelling too. According to a UNFPA
calculation, spending an additional US$79
billion in low- and middle-income countries
by 2030, for example, would avert 400 million
unplanned pregnancies, save the lives of
1 million mothers and 4 million newborns,
and generate $660 billion in economic benefits(UNFPA, 2022).
Yet with all that has been achieved, millions
of people still see little difference in their
daily lives and continue to struggle to realize
their rights, largely because the roots ofgender discrimination and other forms of
marginalization run deep.
The latest data show that, in 69 countries, one
quarter of women still cannot make their own
health care decisions. One quarter cannot say
no to sex with their husband or partner. Nearly
1 in 10 have no choice in using contraception(UNFPA, 2024a). But these data have yet tomotivate significant improvements in women’sbodily autonomy. Only about a third ofcountries even report these data. And for the
first time, trend data on SDG indicator 5.6.1
are available for more than 30 countries, andwhile 19 countries have seen a positive trend
in women’s ability to exercise decision-making
over their own sexual and reproductive health,
13 countries have seen a negative trend in thissame measurement (UNFPA, n.d.).
Once promising progress in reducing preventablematernal deaths has largely stalled: Between

2016 and 2020, the global annual reduction inmaternal deaths was effectively zero (WHO andothers, 2023). That means around 800 women
still die every day while giving birth, and nearly
every one of those deaths is preventable. As
Dr. Mahmoud Fathalla, former Director of theUnited Nations Special Programme on Human
Reproduction, powerfully stated, “Mothers are
not dying because of diseases we cannot treat.
They are dying because societies have yet to makethe decision that their lives are worth saving”(Fathalla, 2012).
And maternal deaths are a telling microcosm of
the inequalities that plague all aspects of sexualand reproductive health because of how blatantthe disparities are – between countries and withinthem. The difference between living and dying
can depend on where a woman gives birth,
as the vast majority of maternal deaths, over
70 per cent, take place in sub-Saharan Africa,
home to many of the world’s least developed
countries and most fragile health systems. A
woman in this region who experiences pregnancy
and childbirth complications is around 130 times
more likely to die from them than a woman inEurope or North America. Inequities withinregions and countries are also wide and deep. In
Madagascar, for example, the richest women are
five times more likely than the poorest to haveskilled assistance when giving birth (UN Womenand others, 2023); and across the Americas,
people of African descent are more likely toexperience obstetric mistreatment (UNFPAand others, 2023).
Inequities are also seen in access to modern
contraceptives, including disparities basedon race and ethnicity (Jackson and others,2017), refugee and migration status

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(Raben and van den Muijsenbergh, 2018),
education, socioeconomic status, and rural
versus urban location (Makumbi and others,2023). And while gender-based violence is both
pervasive and underreported, there are signs ofinequities here, too – including disparities basedon age (Decker and others, 2015) and sexuality(Evens and others, 2019), as well as racial, ethnic
and gender-based disparities in years of life lost
due to intimate partner violence (Graham andothers, 2021).
Despite these inequalities – or perhaps becauseof them – too few countries are collecting dataon sexual and reproductive health needs andbarriers; fewer still are disaggregating thesedata by factors known to contribute to neglect,discrimination and marginalization, factors
including culture, ethnicity, race, caste, language
and religion, disability status, HIV/AIDS

status, migration status, sexual orientation andgender identity.
At the same time, new challenges are arriving
quickly in the digital realm. Health-care
technologies are evolving rapidly and offer
tremendous promise in improving information,easing bureaucracy and extending access to care.
Yet millions of people remain stranded on thewrong side of a digital divide. Technologies suchas artificial intelligence can replicate existing
biases and discriminatory norms, potentiallyworsening inequalities. Some computerassisted diagnostic systems, for instance, areshown to be more accurate for white men
than people of other races and genders (Muroand Egbokhare, 2023). New research also
highlights how technology offers a dangerous
new avenue for gender-based exploitation andabuse (UNFPA, 2024b). Gender inequity can be12

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3/28/24 11:13 AMbaked into the very design of technologies, withwomen underrepresented in training algorithm
decisions. Gender-biased health technology
can be especially problematic, leading todelayed or incorrect diagnoses and treatments.
Women’s representation in early phase clinical
trials is as low as 22 per cent, and pregnant andbreastfeeding women continue to be excluded
from even postmarket stage clinical trials(Ravindran, 2020; Shields and Lyerly, 2013).

and rights is often rationalized in the name of
tradition and cloaked in nostalgia, it contradicts
long-agreed consensus and core human rights
agreements, denies well-established scientificand medical knowledge, and contributes topolitical division and instability (Kanem, 2023;
Guttmacher Institute, 2017).

The ICPD agenda was born from thecommitment of people from all walks of life tocome together and find solutions to common
concerns about population and development,
reflecting “major shifts in attitude among
the world’s people and their leaders in regard
to reproductive health, family planning andpopulation growth” (UNFPA, 1994). The
powerful momentum it unleashed has sincesustained and renewed progress on sexual andreproductive health and rights. Although nocountry can yet claim it has reached everyone,almost every country can celebrate significant
advances. Many have committed to accelerating
progress, recognizing it is integral to the2030 Agenda for Sustainable Development
and its 17 SDGs.

Resistance to sexual and reproductive health andrights is resulting in greater marginalization forcommunities already left – or pushed – behind.
Efforts to control fertility and restrict bodily
autonomy disproportionately affect migrants,
people with disabilities, and minority andindigenous communities, among many others.
A lack of comprehensive sexuality education
limits rights to information and education,and may be more likely to derail opportunities
for young people with fewer resources to seek
accurate answers to their questions. The stark
denial of the rights of people with diverse sexual
orientations and gender identities has escalated(El Chamaa, 2023). Amid the global trend
towards decriminalizing LGBTQIA+ sexuality
and identity, there has been an intensification ofpenalties within those countries that continue
to criminalize LGBTQIA+ persons – including
punishments as severe as the death penalty –despite clear evidence that criminalization not
only increases HIV rates and leads to humanrights violations, but also negatively impacts
economies (HIV Policy Lab and others, 2023).

Multiple crises, however, including conflict,climate fallout and the COVID-19 pandemic,
have put decades of gains at risk and threaten
future progress. Further, a relentless, wellorganized effort to push back against humanrights and gender equality is under way. While
opposition to sexual and reproductive healthRegression and polarization leave societies
less stable and trusting than they otherwise
might be, and more prone to disinformationand falsehoods (Gupta and others, 2023;
Osmundsen and others, 2021). To move
forward, we can start with what we agree upon:that no woman should die while giving life; thatPushing back – andpushing forward

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3/28/24 11:13 AMevery individual has the right to decide when,
whether and with whom to start a family; thatevery person should be able to make choices
about their bodies without violence or coercion;that when women and girls can chart theirown destiny, they and their societies prosper.
Further, as the ICPD implicitly acknowledges,
the rights and well-being of any one person are
inextricably linked to the rights and well-beingof others. Where rights are at risk for one person,
they are effectively at risk for us all (United
Nations, 2020).
This principle was well understood by thefeminist and other movements that came
together with Member States to forge the ICPD
agenda: In the lead-up to the September 1994
conference in Cairo, a broad cross-sectionof women came together from around theworld. They mobilized to make sexual andreproductive health and rights a cornerstone ofwomen’s rights activism and central to poverty
eradication, sustainable development and therealization of human rights as a whole (Corrêa
and others, 2015). Nine months before the
ICPD, women from 79 countries took part in a
global preparatory conference in Rio de Janeiro,
where they took a strong stand against coercive
population policies and pointed to inherent
structural inequities as the “underlying basisof increasing poverty and marginalization of
women, environmental degradation, growing
numbers of migrants and refugees, and the riseof fundamentalism everywhere” (Anon, 1994).
Four months before the ICPD, a collective ofBlack feminists in the United States responded tointernational momentum by launching a call for
reproductive justice – a concept that goes beyond
access to reproductive health care to tackle
multiple forms of economic, social, political and

14

environmental injustice, all of which impact
sexual and reproductive health and rights andmust be addressed to yield holistic results for themost marginalized (Ross, 2017).
Today, a wide range of people’s movements
is reiterating these ideas in a renewed call forjustice and development. Diverse constituencies,
often led by marginalized peoples, are coalescing
and linking concerns that are converging aroundthe world, from the right to bodily autonomy
to the desire for a liveable planet. Their sharedreach is powerful and promising, with researchsuggesting that large-scale social change can takeoff as soon as about 25 per cent of people standin favour of it (Sloane, 2018).
Many points of light include the increasingalignment of diverse grass-roots movements
and civil society organizations with efforts tosecure reproductive health and rights, and viceversa. Indigenous women are mobilizing to end
the destruction of environmental resources,
for example, because it threatens not just theirculture and their sense of connection to the land
but also their health and choices to bear children.
Young activists are campaigning for climate
justice with growing recognition that climate
justice is also reproductive justice (McGovern
and others, 2022). They have stressed that poor
communities hardest hit by climate change arealso those falsely blamed for worsening the crisis
because of their high fertility rates – even as
most greenhouse gas emissions still emerge fromwealthier, lower-fertility countries.
In India, Dalit activists have argued for legal
protections for women facing caste-based
discrimination in workplaces and education.
Many will otherwise remain too poor to support

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3/28/24 11:13 AMtheir families and give their children a dignified
life, contributing to a cycle that perpetuates poor
sexual and reproductive health. Almost half ofDalit women, for instance, receive no antenatalcare, and high rates of gender-based violence areconsidered a means of oppression and control(McGovern and others, 2022).
Cases where women’s rights have been largely
obliterated, as in Afghanistan, have unified
women’s activists, human rights defenders,politicians and prominent jurists behind a move
to define gender apartheid and make it a crime
against humanity (Bahous, 2023; Nia, 2023).

The Green Wave movement sweeping acrossLatin America, which emerged from protests
against shockingly high rates of femicide, hastransformed activism as well as abortion laws ina region once known for some of the strictest
limitations (Carpenter, 2019). As one activist
said, “The cries of anger, pain, joy and sisterhoodon the streets have certainly placed the feminist
movement at the centre of public attention
as a strong and necessary movement that isrequesting radical changes in life as we know it”(Kharas and others, 2019).

Rollback as a response to progress
After decades of progress, there has also been a recent rollback in sexual and reproductive healthand rights. Comprehensive sexuality education, once the subject of near-universal agreement, hasbeen increasingly contested in international negotiations, for example (United Nations, 2023a).
Advocacy organizations are reporting that abortion restrictions in one country are having a ripple
effect in others (Fòs Feminista, 2023), with medical professionals increasingly uncertain about thelegality of basic sexual and reproductive health services (Kanem, 2023).
But pushback can be a common response to progress. As the United
Nations Ofﬁce of the High Commissioner for Human Rights notes,“In several countries, the authorities have noted a dramatic spike inhomophobic and transphobic violence in the immediate aftermathof high-proﬁle legislative advances aimed at better protecting therights of LGBT people. It is a phenomenon with historic parallels:
past attempts to eradicate racial segregation and discrimination
reportedly triggered a similar backlash directed at members of
racial minorities” (OHCHR, n.d.). The challenge, therefore, is tosustain hope and momentum in the face of opposition.

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FEATURE

When crises cut off health care,
community members fill the gaps
Duha, a 28-year-old single mother,
was already a refugee from the war
in the Syrian Arab Republic, living
in Türkiye’s Hatay Province, when
two powerful earthquakes struck in
February 2023. The disaster forced
her and her three young children
from their former precarious
housing and into a makeshift tent.
Duha became pregnant in theaftermath of the crisis, andsuffered for months from a painful
urinary tract infection; she says thisis common among the earthquake
survivors, given the unsanitary
washing facilities. “The lack ofclean water has led to many kindsof infections.”
One of her biggest concerns was
the scarce access to health care:
Regulations under Turkish law
allow registered Syrian refugees
with temporary protection status
to visit family and migrant healthcentres without paying. But inHatay, near the epicentre of thequakes, many services wereincapacitated, and others wereat risk of buckling under theincreased demand.

16

Fortunately, Duha was able toreceive treatment from Dr. Eda
Gülüm, a doctor working with
HASUDER, the Turkish Associationof Public Health Specialists,
members of which have paidfrequent visits to women and girls
in the earthquake-affected areas.
Mobile units with HASUDER,
supported by UNFPA, provide
prenatal and postnatal
consultations, as well as familyplanning advice and treatment forcommon conditions such as cystitis,
vaginitis and urinary tract infections.
They also deliver group information
sessions on breast cancer
awareness, personal hygiene, familyplanning and preventing sexuallytransmitted infections.
“We performed an abdominal
examination and checked her vital
signs,” Dr. Gülüm says. “We also
made sure she wouldn’t miss herroutine prenatal visits and gave hera ‘maternity kit’, which includes baby
clothes, a blanket and toiletries.”
Duha began organizing others toseek care. “Duha was ﬂuent inTurkish and very eager to help thehealth staff communicate withmore women, contacting doctors
and gynaecologists whenevera woman in her neighbourhood
needed them,” Dr. Gülüm says.
Globally, the human right tohealth is articulated in many
international agreements, but
in displacement, conﬂict andother crisis settings, this rightis often threatened or violated.
Existing health systems can becompromised, patient populations
may be uprooted and emergency
responses may fail to prioritize
sexual and reproductive healthservices – with consequences
falling disproportionately on
women and girls.
Dr. Gülüm and HASUDER are
trying to bridge these gaps.
Dr. Gülüm is ﬂuent in Arabic
and English as well as Turkish.
Since August 2023, she has
been serving quake-affected
communities, typically seeing
10 to 30 women each day. When
she’s with the mobile unit, she
can visit up to 80.

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“The nearest hospital is about 20
minutes away by car,” she explains.
“With no public transport in thearea, the mobile unit also supports
patients in urgent need.”
It’s a situation 22-year-old Rama(name changed), from the Syrian
Arab Republic, faced. She has
also been living in a tent since theearthquake. She reached out to
HASUDER when she discovered
she had miscarried early in her
pregnancy, putting her at risk of lifethreatening sepsis. The mobile teamhelped her gain access to a public
hospital where she was treated.
A few days later, she called themobile team: “I just want to let you
know I got through it,” she said.
For those not intending to become
pregnant, being displaced andlosing access to basic healthfacilities also poses critical risks.
“The most common conditions
I see are sexually transmitted
infections, urinary tract infections
and unintended pregnancies,”says Ceylan Güzey, a nurse andhealth trainer with the UNFPAsupported Youth Approaches to
Health Association (Y-Peer Türkiye)in Hatay. “I also do training andawareness-raising on these, andon family planning.”
Since May 2023, Ms. Güzey has
been working chieﬂy with people
displaced by the disaster; she
explains that the team often
discovers other underlying issues.

Nurse Ceylan Güzey says there’s been an increase in child and unintended pregnancies
since the 2023 earthquakes, as well as reports of sexual abuse, coercion and trafﬁcking.
© UNFPA Türkiye

While distributing maternity kits,
for example, staff may identify
untreated sexually transmitted
infections, or violence or coercion.
“We’ve seen child and unintended
pregnancies rise since the crisis,
as well as reports of sexual abuse,coercion and trafﬁcking… there’s
been a very visible increase.”
To address the prevalenceof unintended pregnancies,
Ms. Güzey is liaising with men
much more than before. “I work
mainly with women, but we’veseen more couples asking foradvice together – it’s unusual,normally men don’t want to go
and ask for contraceptives.”
Although the disruption in services
is leading to harmful outcomes,
Ms. Güzey has seen a surprising
upside to bringing support directly
to those displaced. “Before theearthquake, sexual and reproductive
health work was more hidden, it
was a kind of secret – now men are
more understanding about theseissues. They thought contraceptives
were somehow against them, so it’s
become less of a threat.”

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The language of inequality
The language we use to address inequality matters. It is crucial that we avoid depicting any individual
or community as powerless or peripheral. While there has been a tendency to describe entire groups as
marginalized or oppressed, efforts are increasingly being made to name the speciﬁc conditions that can
impede access to rights and choices. For these reasons, UNFPA has shifted from a focus on furthest-behindgroups to furthest-behind factors. Some experts and organizations now refer to those “pushed behind”(Kharas and others, 2019) rather than “left behind”, avoiding the implication that marginalization is the resultof a community’s own failures or inadequacies. Many use the phrases “leave no one behind” and “reach thefurthest behind ﬁrst”; both principles are central to the 2030 Agenda for Sustainable Development (UNFPA,
2021a). The report uses many of these terms, not to reﬂect a preference for one or another but to adhere to
the source material and/or to bring research together into a cohesive and comprehensible text. The authors
recognize that overall, the language of inequality is ever-changing. We must commit to listening to and learningfrom all members of our societies on a continuous basis.
This report uses the following terms with the following deﬁnitions:
Leave no one behind – from the 2030 Agenda for Sustainable Development (United Nations, 2015).
Leaving no one behind represents the commitment of all United Nations Member States to eradicate poverty
in all its forms, reduce inequalities, and end all types of discrimination and exclusion.
Left behind/pushed behind – individuals who, due to systemic inequalities, face barriers to accessing theirrights and choices. Both “left behind” and “pushed behind” are used in this report.
Furthest behind – individuals who are the most excluded from access to their rights and choices.
Those furthest behind often face intersecting disadvantages that combine to produce extreme hardshipor ostracization. Importantly, this is context-speciﬁc; the circumstances that lead individuals to fall behind
are determined by larger social, political and cultural factors, which can differ substantially from one place
to another.
Equality – the state of being equal, particularly in value, status, rights or treatment under the law.
Equity – fairness; the term “equity” is often used to highlight that an equal distribution of resources oropportunities can still result in unjust or unfair outcomes because of existing privileges and disadvantages.
Inequality – the state of lacking equality, particularly in status, rights or treatment under the law.
Inequity – the state of lacking equity.
Marginalized – a person or group treated as insigniﬁcant, lesser or peripheral by virtue of their identity.
A person can be marginalized because of their sexual identity, race, ethnic identity, religious identity, class,caste, level of education or economic status, or disability, among other things.
Vulnerable – susceptible to exploitation, abuse or other forms of harm; this term is widely used but can beproblematic if the factors that lead to vulnerability, such as denial of opportunities or barriers to services, are
not acknowledged.

18

CHAPTER 1: A work in progress

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FIGURE 1

Factors, in addition to gender, that push people behind      
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   ¦            
  

¦
 §   







HIV
statusSexualand gender
identity

Culture, ethnicity, race,   
language, 
religion 

 
Income

   
 

     


   
¢£¤¢ £¤ ¢ £¤
¢£Disability

Age

Migratory
statusLocation¥   
 


¥  

 
 ¡        S TAT E O F W O R L D P O P U L AT I O N 2024

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3/28/24 11:13 AMWe know more than everabout the levers of change
If some people are still pushed behind, thereis scope – and hope – for rapid progress basedon global agreements to achieve equity, notably
a core theme of the 2030 Agenda (United
Nations System Chief Executives Board for
Coordination, 2017). Among the reasons for
optimism is research showing that improvements
in reproductive and maternal health coverage
have advanced faster among the poorest
populations in recent years (Ghebreyesus andothers, 2020), though progress has been uneven,with well-off groups continuing to maintain
substantially higher levels of health coverage(Amouzou and others, 2020).
Also encouraging is the mounting body ofknowledge about who remains pushed behind
and why, and what to do about it. Poverty
is increasingly seen as only one driver of
inequalities. Progress also diverges significantly(Ghebreyesus and others, 2020) when
considering other factors that create barriers
to services, lead to poorer health outcomesor otherwise limit fulfilment of sexual andreproductive health and rights. These factors
include gender as well as age; culture, ethnicity,
race, language and religion; disability status;
HIV/AIDS status; location of residence;migration, asylum and displacement status;and sexual orientation and gender identity.
This list is not exhaustive – and even amongpeople who share a disadvantage, complex anddiverse circumstances can abrogate their right tosexual and reproductive health in varying ways
(UNFPA, 2021a). In all cases, a core humanrights principle remains: Wherever and however20

discrimination, bias, vulnerability and inequality
arise, they always warrant corrective action.
Since 1994, major international agreements haveclearly defined responsibilities and obligations
to close disparities in sexual and reproductive
health and rights. They have codified the rightsof people with disabilities and of indigenous
peoples, adding to existing conventions on
women’s rights and the elimination of racial
discrimination. Forward-looking regional
agreements include the Montevideo Consensus
on Population and Development, with its
commitment to promote and protect sexual andreproductive health and rights as essential tosocial justice and sustainable development. The
groundbreaking Protocol to the African Charteron Human and Peoples’ Rights on the Rights of
Women in Africa, better known as the Maputo
Protocol, has led to the removal of abortion
restrictions in over half a dozen countries,
including colonial-era prohibitions linked
directly to high levels of maternal mortality(see page 60 on colonial history) (McGovern
and others, 2022).
Understanding and agreeing to redress thefactors that push people and communities
behind can propel new choices – and with theright choices, the race to reach all people canbegin, at the pace and scale required. Manylevers of change are well known and welldemonstrated. These start with redressing thepower imbalances embedded in societies, laws,
economies and health care, because it will bedifficult if not impossible to achieve inclusion insystems that remain intrinsically discriminatory.
A deliberate rebalancing of gendered power
relations is required on all levels, for instance,from families to parliaments, alongside efforts

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Humanitarian crises drive marginalization
Humanitarian emergencies disproportionately affect women and girls, persons withdisabilities, indigenous persons, persons with diverse gender identity and sexual orientation,older persons and adolescents. Pre-existing gender inequalities and discrimination against
marginalized groups are exacerbated during crises. Gender-based violence also spikes, yet
the prevention, mitigation and response to gender-based violence remains one of the mostunderfunded and least prioritized humanitarian sectors (OCHA, n.d.). Insufﬁcient funding ina crisis increases vulnerabilities for those at risk: Survivors can be left without access to vitalcare, for instance, and cuts to food aid and other assistance are closely linked with increases
in gender-based violence. In Chad, when two new refugee sites could not be established,
many displaced women and girls were left living in an overcrowded camp with insufﬁcient
protection from violence (OCHA, 2023).
Meagre resources also limit health-care access for people in hard-to-reach areas. In Ethiopia,
this meant mobile health teams could reach only 36 per cent of targeted people, with many
remote communities going underserved. And in Afghanistan, around 170 static and mobile
health facilities had to be discontinued, limiting primary health care for 1 million people,
including pregnant women, children and persons with disabilities (OCHA, 2023).
However vulnerability is only half the story. Local women and women-led organizations
on the frontline of emergencies are key actors in ensuring the needs of marginalized
communities are met. Their full, equal and meaningful participation must be ensured andtheir leadership strengthened. While these organizations continue to be underfunded andunderrepresented, progress is taking place. In 2023, 10 humanitarian country teams had atleast one local women-led organization as a member. In Yemen, the humanitarian country
team included two local women-led organizations and a local organization for persons
with disabilities. Thirteen of 19 advisory boards for country-based pooled funds, which
allocate funding to humanitarian actors, had representation of at least one local women-led
organization. These are promising steps, but many more are needed.
This text was contributed by the United Nations Ofﬁce for the Coordinationof Humanitarian Affairs.

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FEATURE

Women garment workers organize
against gender-based violence“Garment workers can raise their
voices against workplace violence
without the threat of retribution,”says Thivya Rakini.
This represents a sea change forthousands of the garment industry’s
predominantly young female
workforce, explains Ms. Rakini,president of the Tamil Nadu Textile
and Common Labour Union (TTCU).
With over 2,000 mills employing
280,000 workers, Tamil Nadu isIndia’s largest producer of cotton
yarn, supplying both domestic andinternational markets, including
well-known fashion brands. Most ofthese employees are young women,
while management and supervisors
are mostly male. This uneven power
dynamic is exacerbated by thegarment workers’ caste and migrant
status, and by corporate efforts toavoid accountability for wrongdoing.
Existing unions were reluctant toaddress issues such as genderbased violence and harassment. “In
Tamil Nadu, the garment industry
is dominated by male-led tradeunions, and the management andsenior leadership are also men.

22

Women’s issues never really had
space,” says Nadita Shivakumar, anadviser with the TTCU. “What women
workers wanted was for the labour
movement to ensure gender-related
issues are part of the core agenda;
it’s not just about wages.”“The workforce is 80 per cent
women, 60 per cent of whom arefrom the Dalit community” – amarginalized caste in India, explains
Ms. Rakini. “But the management
and line leaders are men of theupper castes. It is not easy for themto listen when a Dalit worker says,‘You are doing this wrong.’ That issomething they ﬁnd really hard.”
Frustrated, women garment
workers made the decision to beginorganizing themselves, and the
TTCU was born. It is one of theﬁrst women-led labour unions in
Tamil Nadu, and it is also Dalitled. Membership grew quickly;
it now represents more than
11,000 workers. Trust between its
leadership and members enabled theunion to act decisively when tragedy
struck: In January 2021, Jeyasre
Kathiravel, a Dalit woman andmember of the TTCU, was murderedby her supervisor at a Dindigul
garment mill owned by Eastman
Exports, following months of sexual
harassment. Her death marked
a breaking point; her colleagues
wanted not just justice for Kathiravel
but systemic change to protect all
women garment workers.
“What was different in Jeyasre’s
case was that this was a village
where the TTCU had a verystrong union presence,” says Ms.
Shivakumar. “The women had
been in the union for a very longtime. Jeyasre’s mother was in
the union, and Jeyasre was in theunion. So because it was such avillage and such circumstances,
there was strong solidarity and thegeneral tendency to fall back to
self-blame was not there[...] It was
like whatever happens, we don’tcare, we’re going to ﬁght. It wasthat ‘Me Too’ moment, you know,
for factory workers.”
Their grief and frustration fuelled
a global campaign, “Justice forJeyasre”. It culminated in the
April 2022 signing of the Dindigul

CHAPTER 1: A work in progress

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Agreement to Eliminate GenderBased Violence and Harassment,a historic deal that enshrines
multiple layers of protection in theworkplace through a set of supply
chain agreements with a system ofchecks and balances intended toensure accountability for genderbased violence and harassment at
all levels. If management does notadhere to the stipulations of theagreement, brand signatories arelegally required to impose businessconsequences on Eastman Exports
to ensure compliance. Signatories
include the supplier, the TTCU andthe union’s allies, including the Asia
Floor Wage Alliance and the Global
Labor Justice — International Labor
Rights Forum. The agreement wasalso signed by international fashion
brands that purchase garments fromthe factories, including the H&M
Group and Gap Inc.
Today, Ms. Shivakumar explains,“There are women leaders in eachproduction line acting as shop ﬂoor
monitors. They have a lot of power
to raise issues and they will not
face retaliation.”
And the impacts extend beyond
the workplace, too. Many garment
workers in Tamil Nadu are domestic
migrants who stay in factoryarranged hostels and use factoryarranged buses; both were sitesof exploitation. “Drivers harass
women, saying ‘If you give me asexual favour, even if you come late
I’ll wait for ﬁve minutes,’” says Ms.
Shivakumar. Business owners used
to shrug off any responsibility. “Theyused to say, ‘These are contracted
services. It’s not our responsibility.’”Members of the TTCU celebrate the signing of the Dindigul Agreement. © TTCUThe Dindigul Agreement addresses
this. “We’ve tried to cover not just theworkplaces but buses that transport
workers and hostels, because a lotof the issues happen on buses… Now
we’ve got monitors on the buses.”
One year on, the results of theagreement have exceeded the
expectations even of its founders.
Ninety-eight per cent of total
grievances have been resolved (Asia
Floor Wage Alliance and others,2023), including 100 per cent ofcomplaints related to gender-based
violence and harassment. Over 2,000
workers have received training on
identifying and preventing abuse,including senior management,
support staff and external
contractors. The agreement has
also had positive results for the
manufacturer. In September 2022,
the Dindigul garment factory wasremoved from a list of manufacturers
banned by the United States for
suspicion of forced labour; theDindigul Agreement was credited in
the decision.
“In one year, we have made theworkers understand that we are forthem,” says Ms. Rakini. “But now the
top management also understands
that we are not for the workers alone,
just protesting against management.
We are also for the business.”
Now, the TTCU is negotiating forthese protections to be expanded toother suppliers – but it is determinedthat each new agreement must be
tailored to the needs of the workers
it covers. “Wherever it goes, theagreement should speak to the local
issues of women workers. That’s thelesson that we learned,” says Ms.
Shivakumar. “Now what we need is
to expand the agreement to moreplaces so that these protections areavailable in every factory and thisbecomes the norm. That’s what weneed to do.”S TAT E O F W O R L D P O P U L AT I O N 2024

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to extend and improve the quality of services
and to shift norms and behaviours (George andothers, 2020; Herten-Crabb and Davies, 2020).
Concepts such as sexual and reproductive justice
have been developed to acknowledge and act
on the multiple drivers of discrimination andinequity, including through a deliberate call for
people themselves to define what equity looks
like and requires (McGovern and others, 2022).
Examples of how structural shifts can happen
include the decline in child marriage inSouth Asia, which has emerged throughmore education for girls as well as changes in
economies that opened options for women’s
employment (Herten-Crabb and Davies, 2020).

24

A recent pledge to end child marriage by four
countries that are home to one fifth of allchild brides drew on emerging evidence of an
integrated package of solutions that comprisegender-responsive social assistance, inclusive
labour-market policies and universal secondary
school education, among others (Indira andothers, 2023).
Much better data have been collected since the
ICPD, helping to steer new programmes andinvestments. In 1994, we knew little about
the scale of maternal mortality, for example;
data were often unreliable or uncollected.
Today, the figures are largely in place on an
aggregate level. Further, population and health

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data collected by international institutions
and national governments are now commonly
disaggregated by sex, income, location andage. Data are increasing rapidly on disability.
More now remains to be done to capture afull picture of all forms of marginalization.
Data on ethnicity, race, language, religion,
indigeneity, migration status and LGBTQIA+
identity remain scarce. More is possible, withthe right commitments, including through thecontinued harnessing of new technologies.
There is a nascent but growing understandingof how health services can help dismantle
discrimination and structural barriers
for those who have been pushed behind.
Midwives have shown promise in bothproviding services and empowering womenin marginalized communities. Growing

evidence indicates that sex-positive sexual
health interventions can reduce stigma; draw
marginalized people to use services, including
for sexually transmitted infections and HIV;and increase contraceptive use (Ford andothers, 2022; Zaneva and others, 2022; Starrs
and others, 2018). Women’s self-help groups
in poor communities have demonstrated
merit in providing both information on
health care and microfinance to respondto economic needs, resulting in significant
improvements in antenatal care and familyplanning indicators. A critical componentof these groups is that women members
determine, on a local level, the terms on
which they operate – a lesson that should
be applied broadly, ensuring participationin decision-making over one’s future is thenorm, not the exception.

Population and health data collected byinternational institutions and national
governments are now commonly disaggregatedby sex, income, location and age.

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Our past, our present,
our future
No one wants a world where half of all
pregnancies are unintended, where women arebattered in their homes or die from preventablecauses in childbirth. We all want a future where
girls and women know they can complete theirschooling, pursue decent jobs, start families
if they wish to do so and become part of andcontribute meaningfully to a healthy, thrivingsociety. This is people-centred development –robust, just and resilient to crisis.
Original research in this report (page 28) will
highlight how barriers to health-care accesshave fallen more quickly for women who are
more socioeconomically privileged and for thosebelonging to ethnic groups that already had
fewer barriers to care. This research also showsthat disparities within countries are greater thandisparities across countries – implicating every
society in the perpetuation of these injustices andcalling for redress at levels both low and high.
Chapter 2 of the report highlights why this is
so. Despite 30 years of consensus about the
emancipatory power of sexual and reproductive
health, the systems that deliver this healthcare remain contaminated by deep legacies ofgender inequality, racial discrimination andmisinformation. Yet the process of exposing theseinjustices offers opportunities to develop systems
and practices rooted in the common dignity ofall people.
The third chapter explores the world’s data
revolution – sparked in some ways by the ICPD
itself, which called for disaggregating data to26

identify where, and for whom, unmet sexual andreproductive health needs are most dire. This
directive has gone largely unfulfilled. If the world
is to achieve universal sexual and reproductive
health and rights, the data element of the ICPD
cannot continue to go overlooked.
Chapter 4 highlights the societal, health andproductivity gains that still need to be madeand the investments that can take gains toscale. The case for contraception is by now
incontrovertible. Economists and advocates,
and women themselves, have established thathuman capital development is greatly accelerated
when individuals are able to plan their families.
But investments in contraception alone areinsufficient. This chapter elaborates on thebenefits unleashed by reproductive autonomy
more broadly.
The final chapter looks ahead, using analyses
from a consortium of experts and thought
leaders across the fields of demography, climatechange, health and technology, to anticipate
some of the greatest challenges to both the
ICPD agenda and the world more generally.
This chapter shows that, even amid the looming
storm clouds of populism, disinformation,
climate catastrophe and large-scale displacement,
universal and inclusive sexual and reproductive
health care and rights will remain as crucial,or indeed become more crucial, to securing asustainable and rights-based future for all.
Each chapter begins with a reflection on thepast 30 years of progress, a critical reminder
that, despite current and imminent challenges,
the broader trajectory is towards the fulfilmentof human rights and gender equality. The
chapters then aim to establish a basis of shared

CHAPTER 1: A work in progress

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understanding about the importance ofaddressing discrimination before pointing
to paths forward.
The struggle for health is a struggle for
equality and bodily autonomy (Ghebreyesus
and others, 2020), for justice and for peoplecentred development. It should lift people
and societies up, not push them behind,through choices that all people deserve tohave about their bodies and their lives. To
do this, we must grapple with complexity.
We will have to move beyond measuring
human experience in broad averages that
obscure the experiences of marginalizedgroups. And we will have to advance beyond
a zero-sum accounting, where some people
always win and others always lose. We
can look to the geometry of weaving as
inspiration for an alternative vision of humanpotential. In weaving – which is inherent
to cultures and communities everywhere– the strength of any single thread is vastly
multiplied by braiding. Similarly, theeducation, autonomy, health and potential of
every individual is tenuous alone but vastly
strengthened when woven together withthe rights, health and well-being of others.
Indeed, 30 years ago, the ICPD Programmeof Action affirmed by consensus that sexualand reproductive health and reproductive
rights are enmeshed with, and inseparable
from, the broader aims of sustainable
development. This is both a new and an
ancient way of understanding our world,in which diverse strands come together ina holistic tapestry, in which every life adds
to the fabric of our collective humanity,
beautifying and fortifying the whole.

The Boruca are an indigenous people living in Costa Rica. They collect seeds, flowers,
tree bark, sea snails and other items from the natural world to create the dyes for theirfabric, but first ask permission from Mother Nature to ensure that their practices andtraditions remain sustainable. © Christian Moon/UNFPA Costa RicaS TAT E O F W O R L D P O P U L AT I O N 2024

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IN F O C U S

Self-reported problems in accessing health care,over time, by socioeconomic status and ethnicity

28

Recent years have brought a
proliferation of ways to track andmeasure progress towards theglobal expansion of accessible andaffordable health care (WHO andothers, 2023). Notably, the reportingfor SDG target 3.8.1, coverage ofessential health services, gives
critical insight into the percentage
of individuals receiving essentialcare, the number of health facilities
and personnel per capita, andother internationally comparable
measures. Yet, as this report shows,
it is also important to let people
speak for themselves. The original
analysis elaborated here highlights
how change in health-care accesshas been experienced by womenfrom different socioeconomicand ethnic backgrounds, as they
themselves report.

have a serious problem: (1) withthe distance to a health facility;(2) with getting money needed fortreatment; (3) with not wanting
to go alone; or (4) with getting
permission to go. In only 25 of the
69 countries – about one third of
the total – have the questions beenasked in more than one survey
while also identifying a woman’s
ethnicity. This data set offers an
opportunity to examine women’s
self-reported problems accessing
health care, looking both acrosstime, by socioeconomic factors(wealth quintile, level of schoolingand urban or rural residence) andby ethnicity. Together, these 25
countries represent about one thirdof the global female population,and identify nearly 300 different
ethnic groups.

In 69 countries around the world,
Demographic and Health Surveys
have done precisely that. The
surveys ask women to reporton whether they have serious
problems in accessing healthcare for themselves when they
are sick. Among a larger list ofvarious types of problems, there
are four speciﬁc issues that havebeen asked across all country
contexts, namely, whether women

It is worth emphasizing that theseself-reported answers to healthaccess questions are very different
from measures of universal
health coverage (WHO and others,
2023a), and, importantly, thelevels and trends of both cansometimes be in conﬂict with one
another. Demographic and Health
Surveys are among a variety ofstudies and surveys being used
to evaluate health access, which

can together bring nuance to thisimportant topic.
Overall improvement, unequal pace
The ﬁndings show a promisingoverall trend of reduction in
problems accessing healthcare. According to the mostrecent surveys (which took
place between 2012 and 2022,
depending on the country),
61 per cent of women reported
one or more serious problems
in accessing health care forthemselves when they were
sick – improvement over the ﬁrst
survey period (2000–2018), when
67 per cent of women reported
serious problems accessing
health care.
Nevertheless, the analysis alsoﬁnds considerable inequalities
across countries. For example,
in the most recent survey period,
43 per cent of women in Gambia
had serious problems obtaining
health care while 95 per cent of
women in Peru did. And while mostcountries have seen women report
improved access between the ﬁrst
and second surveys, a handful ofcountries saw little change (Gabon,
Gambia, Malawi, Nigeria, Peru andSierra Leone) or showed evidence

CHAPTER 1: A work in progress

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FIGURE 2

Proportion of women with serious problems in accessing
health care for themselves when they are sick, by country                   ­­       ­ ­

   

   
     
¢ ¦     £of regression (Kenya, Pakistan and
Senegal).
Furthermore, inequalities withincountries are often greater than the
difference across countries. That is,the differences that appear acrosssocioeconomic groups and ethnicities
within the same country usually
exceed the gap seen in the averages
between countries (i.e., Gambia
compared to Peru). For example, in2017 in Albania, 91 per cent of Roma
women with the most marginalizedsocioeconomic status – urban
women with no education and in thepoorest wealth quintile – had serious
problems in accessing health carewhile only 5 per cent of ethnic Albanian
women from the most privilegedsocioeconomic status – rural womenwith higher education and in the richest
wealth quintile – had serious problems.
Likewise, while 18 per cent of urban
Senoufo women with higher educationand in the richest wealth quintile
had serious problems in accessing
health care in Burkina Faso in 2021,
95 per cent of rural Touareg/Bella
women with no education and in thepoorest wealth quintile did so.
Wealth, education, residence
contribute to widening gaps
Women with the most marginalizedsocioeconomic status, who started
out in the ﬁrst survey with a higher
prevalence of serious problems
accessing health care, saw theleast change over time on average.
Those with the least marginalizedsocioeconomic status, who reported
the lowest prevalence of serious

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problems with access, generally
saw the most improvement overtime, a ﬁnding highly reminiscentof other health research revealing
similar patterns of inverse equity(Victora and others, 2018). Thesesocioeconomic designations –which look at wealth, education andresidence – are all country-speciﬁc,with some countries seeing moreadvantage among rural residents
and others seeing more advantage
among urban residents, for example,(see technical note 154).
On average, the most marginalizedsocioeconomic groups saw a
5 percentage point decline in
the proportion of women withserious problems in health-careaccess between the earlier andlater surveys. By contrast, inthe least socioeconomicallymarginalized group, the proportionof women with serious problems
in health care access declined by
8 percentage points.
Ethnicity plays a persistent rolein inequality
Health disparities occur acrossa broad range of dimensions,
including ethnicity. This researchlooked at how ethnic groups fared
over time in access to health care;groups with higher proportionsof women experiencing serious
problems were considered to be
more marginalized, and those withlower proportions facing accessproblems were considered lessmarginalized. Ethnicity-based
differences persist even after
accounting for different levels

30

of education, wealth and urban/
rural residence. In plain language,
women with the same levels of
education, wealth and place ofresidence, but different ethnicities,
often report vastly different realities
when it comes to accessing
health care. Across all countries,
43 per cent of women from theircountry’s most disadvantaged
socioeconomic proﬁle and least
marginalized ethnicity faced serious
problems accessing health care; forwomen from their country’s mostdisadvantaged socioeconomic
proﬁle and most marginalized
ethnicity this percentage was 83 –a 40 percentage point span among
women who shared the samesocioeconomic challenges and only
differed by their ethnicity.
Furthermore, despite most countries
seeing overall improvements inaccess, more than half of countries
analysed saw ethnic disparities
widen between the two survey
periods. In the 14 countries
with a widening ethnic gap,
the earlier surveys showed a
41 percentage point gap between
socioeconomically disadvantaged
women from the most versus
the least marginalized ethnic
groups, while in the more recent
surveys, the gap increased to48 percentage points.
The trends among all the ethnic
groups identiﬁed across the
25 countries are diverse, but theoverarching tendency is clear: Ethnic
disparities in self-reported problems
accessing health care exist inalmost every country and society
where data are disaggregated for
ethnicity. That is, when we listen
to women’s own reports aboutproblems accessing health carewhen they are sick – using surveys
representing one third of the female
population of the planet – we seethat ethnic disparities in healthcare access are pervasive and, in a
number of cases, widening.
Narrowing the gap is possible
However, there is some good
news. Ethnic differences are notextreme everywhere, and there arepromising signs that narrowing
the gap is possible. In Guinea,
the poorest rural Guerzé womenwith no education saw the highest
proportion with health-care accessproblems of any ethnic group,
96 per cent, in the earlier survey,
but by the most recent survey the
proportion with serious problems
had declined to 72 per cent – better
than rural women from all otherethnic groups with similar levels ofpoverty and schooling. In the earlier
Nigerian survey, among the poorest
rural women with no education,
87 per cent of Ekoi women reported
serious problems in health-careaccess. By the most recent survey,
that proportion had fallen to64 per cent, nearly the same aspoor rural Hausa women, the ethnic
group reporting the best access.
(Still, these improvements were notshared universally among all ethnic
groups within these countries.)
One particular bright spot was
Ghana, where there was only a

CHAPTER 1: A work in progress

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3/28/24 11:14 AM3 percentage point difference in the
proportion of Akan women with themost marginalized socioeconomic
proﬁle facing serious problems inaccessing health care comparedwith Ga and Dangme women,
whereas in the earlier survey it was
a 16 percentage point difference. In
fact, inequality across several otherethnic and socioeconomic groups in
Ghana also diminished between theearlier and later surveys, a sign ofnot just improved access to healthcare but also improved equity.
Why was Ghana so successful
in closing equity gaps comparedto other countries? One possible
explanation relates to the
expansion of access to healthcare in Ghana over the period
covered by these surveys,
including the introduction of afree maternal health-care policy
and the continued roll-out ofa national health insurance
scheme (Aikins and Koram, 2017;
Blanchet and others, 2012).
Many other countries havealso adopted national healthinsurance schemes, but in Ghana
equity seems to have been adeliberate tenet of health-careaccess efforts – not just in
how initiatives were designed
but also in the prioritization ofevidence-driven evaluation andreform (Phillips and others,2020). For example, where othercountries with national healthinsurance schemes might rely
heavily on private out-of-pocket
expenditures, Ghana dramaticallyincreased the portion of health

FIGURE 3

Ghana. Proportion of women with one or more serious problems
accessing health care: socioeconomic extremes, by ethnicity         







   
   
   







 





 ­  
¦        ﬁnancing from public funds(Odeyemi and Nixon, 2013).
Insisting upon progress for all
Overall, the analysis from these
25 countries offers importantlessons to all nations andcommunities. Namely, global
progress in improving access tohealth care has been uneven and,by many measures, those who arefurthest behind remain among thelast to be reached.

in health-care access should
therefore not be regarded as anaccusation of bias or an appeal
to politics. Rather, ethnic andsocioeconomic disparities are
seemingly universal – while
progress towards eliminating thesedisparities is not. But progress ispossible. And it starts by giving
people the opportunity to identify
their experience of inequality in theﬁrst place.

Additionally, ethnic disparities are
not limited to certain countries
but rather are identiﬁable
everywhere adequate ethnicity
data are collected. Highlighting
the existence of ethnic andsocioeconomic disparities

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swp2024-english-240327.indd 32

3/28/24 11:14 AM

STATE OF WORLD POP ULA TION 2024

CHAPTER 2


   33

swp2024-english-240327.indd 33

3/28/24 11:14 AM

The ICPD Programme of Action emerged in theaftermath of the Cold War, a time of upheaval
and uncertainty. That year, 1994, saw both theend of apartheid in South Africa, which held its
first multiracial democratic election in April, andthe eruption of genocide in Rwanda that samemonth. Sweden legalized civil unions between
same-sex partners – making it the third country
ever to do so – as the global rate of new HIV
infections was reaching its highest-ever peak    
      
    
        
     
FIRST WORLD
POPULATIONCONFERENCE,
ROME(UNAIDS, n.d.). The promise of collective
action, and the perils of failing to take suchaction, could not have been more prominent in
the minds of ICPD attendees in Cairo.
And indeed a central achievement of the ICPD,
the paradigm shift in the world’s understandingof population and development issues, did result
from the collective efforts of the Member Statesand grass-roots movements. The Programme of

THIRD WORLD
POPULATIONCONFERENCE,
BUCHAREST

This largely academic
conference focusedon demography indeveloping countries;
conversations at thetime were dominatedby fears over
population growth andresource scarcity.

Following a decadeof economic growth,
population cameto be seen as lessof a ‘problem’.
Governments here
agreed on the needfor a new paradigm
around populationand development.

1954

1974

1975

Feminist researchers
used human rights
frameworks to carve arole for themselves.

THE UNITED
NATIONSDECADE FORWOMEN BEGINSInternational
women’s movements
were growing andmobilizing aroundsocial, economic andpolitical issues.

34

CHAPTER 2: Unravelling inequality

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Action introduced the concepts of reproductive
health and reproductive rights – both terms
already in use by the women’s movement
and public health advocates – to the broader
international community (Berro Pizzarossa,2018), and situated these within “human rightsthat are already recognized in national laws,
international human rights documents andother consensus documents” (UNFPA, 1994).
By invoking the wisdom of grass-roots advocates

1976

1977

CONVENTION
ON THEELIMINATION OF
ALL FORMS OFDISCRIMINATIONAGAINST WOMENFIRSTINTERNATIONALWOMEN ANDHEALTHMEETING(IWHM), ROME

(CEDAW) was drafted
and approved by theCommission on the
Status of Women.

The international
women’s healthmovement emerged.

and drawing on the existing human right to health,the Programme of Action was able to secure, byconsensus, recognition that States and healthsystems are obligated to uphold the sexual andreproductive health and reproductive rights andwell-being of all people.
This role for health systems as an enabler of humanrights – not only the right to the highest attainable
standard of health but a suite of other rights – was

1979
CEDAW
ADOPTED BY
THE GENERALASSEMBLY

1981
THIRD
INTERNATIONALWOMEN ANDHEALTHMEETING,GENEVA
Activists from the
Global North andGlobal South united on
reproductive rights andaccess to health care.

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by this point well understood, but in the contested
arena of sexual and reproductive health thisrecognition was groundbreaking. The Programmeof Action even achieved agreement on the hotly
disputed issue of abortion, determining that “incircumstances where abortion is not against thelaw, such abortion should be safe” and that “in allcases, women should have access to quality services
for the management of complications arising fromabortion”. The final text showed that a woman’s

INTERNATIONALCONFERENCE ON
POPULATION, MEXICO
Here discussions broadened
to include both technicaland political demands.

Preparatory committees
and the ICPD Secretariat at
UNFPA began working towards
the 1994 ICPD in Cairo.

1990

1984
FOURTH
INTERNATIONALWOMEN AND HEALTHMEETING, AMSTERDAM

Simultaneously, women’sorganizations and networks
mobilized to influence theexisting population agenda.

The term ‘reproductive rights’
was officially embraced by
the international women’s
health movement.

36“health and personal development are cruciallydependent on the quality of the services she
is offered, and the choices available”, as thenUNFPA Executive Director Nafis Sadik described
the following year in Beijing, at the Fourth World
Conference on Women, highlighting the roleof health systems, doctors, contraception andinformation in “liberating women from a systemof values which insists that reproduction is their
only function”.

1992
WOMEN’S DECLARATIONON POPULATIONPOLICIES
Signed by 2,539 individuals andorganizations from over 110
countries, calling for population
discussions to reorient around
reproductive health and rights.

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And in the 30 years since the Cairo conference,
health systems, education systems andgovernments – and the civil society groups
that hold them accountable – have delivered.
When laws are assessed by whether they
sufficiently guarantee full and equal access tosexual and reproductive health care, informationand education — including maternity care,abortion, contraception, comprehensive sexuality
education, HPV vaccination, and HIV testing,counselling and treatment — 76 per centof such laws are found to be in place across
115 countries, as measured in SDG indicator
5.6.2 (UNFPA, 2024a). Additionally, since
1994, abortion rights have been recognized formillions of people worldwide, as more than
60 countries have revised their abortion laws toremove restrictions (Center for Reproductive
Rights, n.d.), compared to just four that haverolled back the legality of abortion.

INTERNATIONAL CONFERENCE
ON POPULATION AND
DEVELOPMENT (ICPD), CAIROThis was a rare opportunity for political agreement
among governments, held at a unique time inglobal politics: amid the end of the Cold War, on
the heels of the Oslo Accords, and as views on
population issues shifted at the highest levels.
NGO representation was unmatched, with 4,000
representatives from over 1,500 civil society
organizations from 113 countries. Representativesof the women’s movement were also part of nationaldelegations, advocating for their realities and rights
to be included in the ICPD Programme of Action.

1994
PREPARATORY CONFERENCE,RIO DE JANEIRO
Hundreds of women released a statement outlining
principles and conditions needed to ensure a womancentred, rights-focused approach to population.

ICPD+5Youth movements
were engaged tohelp advance the
ICPD agenda amonga new generation.

1995

1999

FOURTH WORLDCONFERENCE ON
WOMEN, BEIJING
This culminated in the
Beijing Declaration andPlatform for Action
and is recognizedalongside the 1994
Cairo conference asa seminal momentin the international
women’s movement.

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The ICPD also called for youth to have access
to, and participate in the development of,“information, education and communication
activities and services concerning reproductive
and sexual health” – acknowledgement that
this information would help to empower
current and future generations to fulfil theirpotential. Since then, international standards
have been developed and today two thirdsof reporting countries state 76 per cent ormore of their schools provide some form of

sexuality education (UNESCO and others,2021). Assisted reproductive technologies
have become almost ubiquitous, enabling
more people to realize their fertility
aspirations and expanding opportunities
for more diverse families.
But much more remains to be done.
Bodily autonomy is a reality for too few
women globally. Today, just over half

ICPD+20
The Millennium
Declaration was
adopted by the United
Nations General
Assembly, followedby the Millennium
Development Goals.
But civil society called
for amendments: The
initial goal on improving
maternal health, forexample, did notcontain any targets on
reproductive health.

2000

Advocates succeeded
in having universal
access to reproductive
health includedin the Millennium
Development Goals.

Once more, experts,
feminists, youth, NGOs
and governments
mobilized aroundthe ICPD agenda,
resulting in a bold
Framework of Actions
for the Follow-up to the
ICPD Programme of
Action Beyond 2014.
The ICPD was also
re-endorsed at theUnited Nations General
Assembly Special
Session on the ICPD.

The 2030 Agenda
for Sustainable
Development was
adopted, leading
to the Sustainable
Development Goals.
Thanks to advocacy,
Goal 3 on health and
Goal 5 on genderequality both included
targets on sexualand reproductive
health and rights.

2005

2014

2015

MDGS + 5

The #NiUnaMenos
movement calling foran end to femicide
emerged in Argentina,
uniting women’s groups
across Latin America
and ultimately leading
to the Green Wave.

38

CHAPTER 2

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(56 per cent) of the world’s women were able to
make their own informed decisions about sex
and reproduction. This means the freedom tomake choices about health care and the use ofcontraceptives as well as to say no to sex witha husband or partner, information collected incountries’ reporting for SDG indicator 5.6.1(UNFPA, 2024a). And while data are limited(explored further in Chapter 3), a growing bodyof evidence indicates that bodily autonomy andreproductive health are more frequently, andGENERATIONEQUALITYICPD30Civil society,youth leadersand government
representatives turned
out in force for sexualand reproductive healthand rights. The Summit
resulted in nearly 1,300
commitments andthe forward-looking
Nairobi Statement.

Due to the global
COVID-19 pandemic, thereview took place a year
late. The Generation
Equality Forums
saw an emboldened
international women’s
movement andreignited support fromgovernments andpartners; this included
an action coalition
dedicated to bodily
autonomy and sexualand reproductive
health and rights.

The thirtieth anniversary of thegroundbreaking Cairo conference.
Feminist and reproductive rights
movements have grown in numbers
and in strength and many gains
have been made – but our work is
far from over. New organizations
and members have mobilized,
including on intersectional
issues such as caste, disability,
indigeneity, sexual orientationand gender identity. These are
creating space for multiple voices
and stakeholders, and social
media is drawing more people,
and perspectives, to the cause.

2019

2021

2024

NAIROBISUMMIT ON
ICPD252017
The SheDecides
movement was
launched in supportof reproductive
health and rights. The#MeToo movement
also erupted, reviving
a 2006 campaign, in
response to millions of
women decrying sexual
abuse and harassment.

more severely, undermined among those facing
one or more forms of oppression, such as
those enduring ethnic or racial discrimination,persecution over HIV status or disability, or
discrimination over their sexual orientationor gender identity. There is increasing
recognition that the capacity to determine
one’s reproductive future – including accessto modern contraception, safe abortion wherelegal, prenatal medical care and childcare –is unequally distributed across race, sexual             
         
      S TAT E O F W O R L D P O P U L AT I O N 2024

swp2024-english-240327.indd 39

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orientation, gender identity, sex characteristics,
class and socioeconomic status.
In fact, the world is only just beginning tograpple with the legacy of multiple formsof discrimination in medicine and healthsystems. As this legacy is unearthed, questions
are being asked about the people who havebeen marginalized, the mechanisms of thatmarginalization and the persistence of its
consequences. Experts are drawing attention to
the structures that perpetuate discrimination,
sometimes invisibly – a contrast to earlier efforts
that tended to focus on individual behaviours(OHCHR, 2021). As a result, discrimination isincreasingly being identified through unequal
outcomes rather than requiring proof that theseoutcomes were motivated by individual animus.

The human right to sexual andreproductive healthSexual and reproductive health and rights are now widely understood, andacknowledged in a number of human rights frameworks (Organization of
African Unity, 1981; OHCHR, 1966), to be grounded in the right to life, todignity, to education and information, to equality before the law and to
non-discrimination; the right to decide on the number and spacing ofchildren; the right to privacy; the right to health; the right to freedomof opinion and expression; the right to consent to marriage and toequality in marriage; and the right to be free from gender-based
violence, harmful practices, torture and ill treatment, as well as
the right to an effective remedy for violations of fundamental
rights.
It is also well accepted (OHCHR, 2019; UNFPA, 2019;
Shalev, 1998) that the key principles that shape humanrights – especially non-discrimination, equality and privacy,
the right to information, as well as the integrity, autonomy,
dignity and well-being of individuals, particularly in relation
to sexual and reproductive health and rights – are integral to
the realization of the right to health.

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This reckoning has been most prominent
in justice systems. The Ni Una Menos
movement in Latin America, for example,
highlighted the passivity of authorities
in cases of femicide and other forms ofgender-based violence. The Black Lives
Matter movement brought attention to thedisproportionate experience of police violence
among Black people globally (OHCHR,2023). Other sectors have been affected aswell: Within education, the Rhodes Must
Fall protest movement drew attention toinequities in higher education, first in South
Africa and then internationally (Knudsen andAndersen, 2019).
This kind of reckoning is just as relevant for
health systems, a fact deeply underscoredduring the COVID-19 pandemic. In many
parts of the world, pandemic emergency
measures were not in conformity withhuman rights law (OHCHR, 2020). Alreadymarginalized populations experienced higher
rates of COVID-19 pandemic-related
illness and death and greater disruptions ofother health services, including for sexualand reproductive health (WHO, 2020).
Contemporary discourse around gender,social and racial justice movements mightsuggest these issues are controversial orpolitical, but it is a mistake to see this process
only through the lens of politics. We canrecognize that the history of reproductive
health includes regrettable tragedies andmissteps without diminishing the many
advances that have been made in science andtechnology. Rather, it allows us to learn fromthe past, creating opportunities for knowledge
and progress – for all people.

Health systems must be
enablers of human rights
Reproductive health systems have not always
been health- and rights-affirming. At least
not for all women. “A major shortcoming in
reproductive health care within the health-caresystem was the philosophy with which services
were provided,” experts have commented.
“Women were considered as means in theprocess of reproduction, and as targets in theprocess of fertility control. Services were notprovided to women as ends in themselves.
Women benefited from the process, but were notat its centre. They were objects, and not subjects”(Cook and others, 2003).
Systems and structures to control sexuality,
especially (but not exclusively) the sexualityof women, have been universal, permeating
all societies around the globe. The bodies
of women, girls and gender-diverse people
were often subject to discrimination, harmful
practices, control, exploitation, violence andoppression – human rights violations that
historically have been abetted by health systems(OHCHR, 2021a). And these issues are all too
persistent today. Many obstacles continue tostand between individuals and their enjoyment
of sexual and reproductive health and rights,
operating at different levels: in clinical care, atthe level of health systems and in the context
of the underlying determinants of health. And
they operate differently for those experiencing
different forms of marginalization.
Health workers are, today, among those bestplaced to identify the transformative value of
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see first-hand how family planning, protection
from violence, safety from disease and accessto maternal health care result in healthier andbetter-educated families and communities.
Many contemporary reproductive health workers
embrace their role in upholding the rights of
their patients (and the topic of patients’ rights
is, in fact, a staple in the education of healthprofessionals globally [Rostami-Moez and others,
2021; Karakuş and others, 2015; Lewkonia,
2011]). Through the provision of contraception,
information and care, reproductive healthpractitioners often stand on the front lines ofindividuals’ efforts to secure bodily autonomy(see feature on page 16) (Kalra and others,2021). Yet they can be subjected to abuse fordoing so. New research shows that, “as [sexualand reproductive health and rights] workers

seek to fulfil the human rights of others, theirown human rights are put at risk”, as they face“ostracization and harassment in the workplace”,“verbal threats and physical violence” andhostilities in their personal lives (Boydell andothers, 2023).
The following sections illustrate how sex
discrimination, racial and ethnic discrimination,and misinformation continue to impact healthservices and information today, making thecase that both human rights and public healthrequire reconciliation with this history. In orderfor health workers to become enablers of humanrights, the health systems that employ them– which have historically been so complicit in
exploitation and abuse, and which today leave
many sexual and reproductive health workers

Health workers as champions of bodily autonomy
A reciprocal relationship exists between the receipt of digniﬁed, quality sexual and reproductive
health care and the experience of economic, social and personal empowerment. Health workers,
in particular, observe directly how reproductive autonomy – the ability to choose whether, when
and with whom to have sex or become pregnant, the ability to live free of violence and preventablesexually transmitted infections, etc. – enables individuals to pursue their education, delay or start
their family, build their career and/or contribute to their community. And they see ﬁrst-hand how
empowered individuals – those able to pursue education, careers and/or families – are better able
to access reproductive health services. The virtuous cycle is an uncontested truth for those who
witness it. “We teach them to expect respect,” says Víctor Cazorla, a male midwife working in theAndes mountains of Peru, who sensitizes his mostly indigenous patients about their rights (UNFPA,2021). “Nobody has a right to touch their bodies: not me, not their aunts, not their fathers, not theirmothers, not staff, not police, nobody.”

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vulnerable to mistreatment – can and should bereformed to realize their original and more noble
purpose, for individuals, health professionals andsociety as a whole: healing.

The legacy of sex
discrimination in
reproductive health care
Understanding the legacy of sexism withinsexual and reproductive health care can actually
help to identify solutions – including costeffective and readily achievable solutions – topersistent problems.
One important example is the history ofchildbirth care, which, for centuries, was largely
considered the domain of women. Women
midwives managed childbirth while physicians, aprofession restricted to men, generally avoided it.
Childbirth was long considered a female mystery,
and women alone had special knowledge
and understanding of it, including the useof herbs as drugs. Over time, male doctors
did begin to assist birthing women, initiallyonly in complicated and high-risk deliveries(Litoff, 1982).
Eventually, doctors and other male-dominatedinstitutions assumed authority over midwives. In
precolonial Indonesia, for example, women reliedon traditional midwives, or birth attendants,
known as dukun, who provided contraception,delivery care and abortion. When Indonesia
became a colony in the 1800s, authorities
sought to replace dukun with midwives trained
under the male leadership of the Dutch medical
service (Adnani and others, 2023). Around thesame time, male physicians in India proposed
the provision of formal training to traditional
midwives known as dai, efforts that ultimately
led to dai being replaced by trained midwives
and doctors working under the medical
establishment (Samanta, 2016).
Midwives were also brought under thejurisdiction of male leaders in Europe in the 16th
and 17th Centuries, when they were licensed bymale-dominated church authorities and, in somecases, compelled to serve as expert witnesses incases of “infanticide, contested virginity, abortionand sterility” (Sprecher and Karras, 2011).
It was during this period that “accoucheurs”(male midwives) became fashionable in France,
creating competition with the so-called “natural
practising” female midwives and popularizing
the use of instruments such as forceps. The
gender and status of men established theirauthority in the field despite having little or nopractical experience (Martucci, 2017). At thetime, men training to be doctors were largely
influenced by writings about birth, written bypractitioners who may never have seen labouror birth (Hobby, 1999), rather than practicalknowledge (Thomas, 2016).
The emerging “science of nature” gave rise to aview of medicine as being objective, part of auniversal system of knowledge, one from whichfemale midwives were largely excluded (Shiva,
1996). Unlike male doctors, they were neither
educated nor involved in the investigative andexperimental scientific methods. By the 18th
Century, the medical profession mostly consistedof men, and midwives were accused of using
ancient, dangerous and outdated practices.
Research on colonial-era South Africa, forexample, shows that the real-world experience

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and knowledge of midwives – especially Black
midwives – was largely omitted from the historical
record (Deacon, 1998). Men’s contributions to
the field, by contrast, were better documented,
enabling male-dominated views of childbirth toprevail. New birthing theories likened the bodyto a machine and childbirth to a mechanicalprocess, a view that further alienated midwives aspractitioners, since women were seen as lacking
the knowledge and ability to understand themechanisms of birth (Murphy-Lawless, 1998).
Birthing bodies were increasingly viewed as
uncontrollable, uncontained, unbounded, unruly,
leaky and wayward (Carter, 2010). In 1915, Dr.
Joseph DeLee, author of the most importantobstetric textbook of that period, describedchildbirth as a pathological process that damaged
both mothers and babies. “If the profession(obstetrics) would realize that parturition viewed
with modern eyes is no longer a normal function…
the midwife would be impossible even of mention,”
he wrote (DeLee, 1915). Dr. DeLee would later
propose interventions, including routine use of
sedatives, ether, episiotomies and forceps – all ofwhich are now known to be harmful when usedroutinely – to save women from the “evils” natural
to labour (Leavitt, 1988).
The sidelining of midwives within obstetric
medicine was a global phenomenon, but today
the consequences are most severe in low- andmiddle-income countries. WHO has identified
Africa and South-east Asia as the regions withproportionally fewest countries recognizing
midwifery as a distinct profession. Midwifery
educators in these regions persistently reportlacking access to toilet facilities, and in Frenchspeaking West Africa, three quarters of midwifery
educators lack access to clean water at least someof the time. Furthermore, WHO’s Africa region

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accounts for 56 per cent of the global shortagein health professionals dedicated to providing
sexual, reproductive, maternal, newborn andadolescent health care (UNFPA and others,2021).
And although midwifery today is widely
understood to be a modern, regulated, technicalprofession well integrated into the healthcare infrastructure, it remains predominantly
female in most places. Research shows the
midwifery workforce suffers under serious
occupational segregation, gender pay gaps, lackof leadership opportunities and multiple formsof discrimination and harassment, including
sexual harassment (UNFPA and others, 2021).
A 2019 WHO report found the gender pay
gap in health care was larger than that in othersectors, with female health workers earning,on average, 28 per cent less than male healthworkers – and an 11 per cent gender pay gap
persisted among nurses and midwives even after
adjusting for occupational segregation (Boniol
and others, 2019).
The undervaluing of midwifery “results in
restriction of choices and job opportunities
for midwives and reinforces unequal power
structures within society”, including a lack ofprofessional autonomy (UNFPA and others,2021), which midwives themselves identify
as a barrier to providing high-quality care
(International Confederation of Midwives andothers, 2016). The 2021 State of the World’s
Midwifery report noted that, in low- andmiddle-income countries, many midwives
struggle or fail to be reimbursed by government
insurance programmes, leaving them to absorb
financial losses or prioritize care for more
affluent patients.

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Yet researchers have long noted that investments
in midwifery training and care would yieldsignificant dividends for maternal and neonatal
health, with lower costs and better outcomesthan more medicalized models of care (UNFPAand others, 2021). A 2021 Lancet Global
Health study, supported by UNFPA, found that
substantially increasing coverage of midwifedelivered interventions could avert 41 per centof maternal deaths, 39 per cent of neonatal
deaths and 26 per cent of stillbirths – equalling
2.2 million deaths averted annually by 2035,
and most of them in low- and middle-income
countries (Nove and others, 2021).
In view of the historical marginalization of
women within obstetrics and midwifery,
it is worth examining the role of gender
discrimination in the world’s continued
underinvestment in midwifery. It is also worth
examining the consequences of these genderedhierarchies in medicine, which affect not only
health practitioners but also the people receiving
health services (and, in the case of neglect andexclusion, those not receiving those services).

experienced during reproductive health care,including during childbirth, is a matterof growing concern to the international
community (OHCHR, 2019a). The concept
is expansive, including verbal and physicalabuse – examples are mockery, threats,punching, kicking, gagging and physicalrestraint (Downe and others, 2023) – aswell as over-intervention such as medicallyunnecessary episiotomy, lack of informed
consent, denial of pain relief (UNFPA, 2019a)
and forced sterilization. Research highlightsthat these forms of mistreatment tend tooccur in “contexts where providers, primarily
midwives, feel unsupported or even victimized
within their professional hierarchies”(Schaaf and others, 2023). Mistreatment
in reproductive health settings contributes
significantly to maternal mortality and createsbarriers to health services for marginalized
women and girls (UNFPA and others, 2023).

Obstetric and gynaecological violence, broadly
described as mistreatment and violence

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FEATURE

Safe, culturally sensitive,
empowering childbirth forColombia’s Afrodescendent women
More than two decades ago, 18-yearold Shirley Maturana Obregón visited
a hospital in Chocó, in Colombia’s
Paciﬁc region, seeking care for acase of gastritis. Despite the factthat she was nine months pregnant
at the time, Ms. Maturana Obregón
never considered staying on andgiving birth there.
“It wasn’t the environment I wanted,”
Ms. Maturana Obregón tells UNFPA.
“I wanted my mum to be there, andwhat I heard [at the hospital] wasthat I was going to be alone.”
So she returned home and soon
went into labour. Her mother andsisters were there to support
her throughout the delivery – aswas a partera, a traditional birthattendant and practitioner ofknowledge ancestral to Colombia’s
Afrodescendent community.
“It was beautiful and unforgettable,”she says.
For Ms. Maturana Obregón, thedecision to give birth with apartera reﬂected her personaland cultural priorities. But
home births also often reﬂect a

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lack of other options. Chocó’spopulation – of which 80 per centidentiﬁes as Afrodescendent –is disproportionately poor andremains largely disconnected from
Colombia’s formal health-caresystem. Getting to a doctor canrequire travel across hazardous,
conﬂict-affected terrain, or cansimply cost too much.
The consequences of not deliveringsafely can be deadly, particularly
for Afrodescendent women andgirls. In Colombia, they are at morethan double the risk of dying due topregnancy and childbirth than their
non-Afrodescendent counterparts.
Yet in seeking to improve maternal
health outcomes, the Colombian
health system has sometimes
alienated parteras and the culturalvalues they represent.
Parteras have been derided as
witches and herbalists, or portrayedas unhygienic and unprofessional.
Historically, Colombian laws
required anyone attending childbirth
to be ofﬁcially licensed by a medical
institution, rules that led to theerasure of the work parteras do,

isolating them from the medical
establishment. Yet along Colombia’s
Paciﬁc coast, parteras are often
the only health provider on hand. In
one town in Chocó in 2021, national
statistics show every birth was
supported by a traditional birthattendant (DANE and UNFPA, 2023).
“Doctors treat us like everything[we do] is ﬁlthy,” says partera
Francisca Córdoba, better known
as Pacha Pasmo. “As I have told
several doctors, you may have ﬁve
years of experience, but you do
not have the experience I have –I started attending births before
you were born.”
But a new initiative is knitting
health workers and parteras moreclosely together. In 2020, thePartera Vital project was launched,aiming to validate parteras’ often
invisible work in providing culturally
afﬁrming care to pregnant andpost-partum women, while also
providing parteras with tools andskills to deliver their services
safely to their communities andin conjunction with the formal
medical system.

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UNFPA’s Partera Vital project seeks to empower traditional birth attendants like Shirley Maturana Obregón (left) and Pacha Pasmo(right) to support pregnant women across Chocó, Colombia. © UNFPA Colombia/Sara Chavarriaga

Through Partera Vital, Colombia’s
national statistics agency worked
together with UNFPA and local
parteras associations to amend
rules barring traditional birthattendants from registering
newborns. Parteras received
a mobile app allowing them toregister births in the national birth
registry; they also came together
for training sessions aimed at
improving risk identiﬁcation during
pregnancy and childbirth.
The project was ﬁrst rolled out
to 30 traditional birth attendants
in Chocó. The parteras also
received scales for weighing
newborns, safe delivery kits
containing items like clean sheetsand gloves, and blood pressure
monitors, which can help them
identify life-threatening pregnancy
complications. “If a partera seesthat a pregnant woman’s bloodpressure is high, they run to refer
her,” Ms. Pacha says.
The project’s impact was
immediately clear during the
COVID-19 pandemic in 2020, when
statistics showed 34 per cent ofbirths in Chocó were supported
by parteras – nearly 50 per centmore than had been recorded in theprevious year. Parteras petitioned
the Government to be recognized
as essential workers amid thecrisis, a change that led to parterasreceiving resources and equipment
to care for their communities.
Most recently, UNESCO, the United
Nations Educational, Scientiﬁcand Cultural Organization,
designated midwifery in Colombia
and other countries an integral
part of humanity’s intangible
cultural heritage.

Partera Vital’s introduction to
Chocó has also corresponded witha major health advancement in theregion: reduced maternal deaths.
“We don’t know yet to what extent
the empowerment of parteras has
contributed to the national efforts
to reduce maternal mortality in
Chocó, but in 2023, maternal deaths
dropped by nearly 40 per cent,”
says UNFPA Colombia sexual andreproductive health adviser Jose
Luis Wilches Gutiérrez.
Since delivering with a partera, Ms.
Maturana Obregón has become one.
“The people we serve – they want
to experience having their children
with a partera, because the partera
puts her in the position she wants
to give birth in,” she says. “We
are there, making those women’s
dreams come true.”

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The legacy of ethnic andracial discrimination
One of the consequences of the COVID-19
pandemic has been a renewed awareness of
the racial disparities that continue to persist
within health systems, and a growing effort
to understand these disparities within thecontext of historical inequities. While many
conversations around racial inequity have been
contentious, the advancement of equity andjustice in health are in many cases yielding
valuable and evidence-based solutions to theseissues. In short, understanding the legacyof racial discrimination, and also the role ofcolonialism in exporting racial hierarchies, isrevealing the many possibilities that exist forachieving equity and justice within medicine.
Historically, many governments have seen
reproduction primarily in instrumental
terms. Childbearing has been promoted
when it is deemed valuable for economic or
political objectives (Juan Bautista Alberdiof Argentina famously said, “To govern isto populate”), and it has been discouraged(often selectively, among groups considered“inferior”) when deemed undesirable.
During colonial regimes, and especially inthe transatlantic slave trade, childbirth wasseen both figuratively and literally as a formof asset production (UNFPA, 2023b). In
Africa and the Caribbean in the early 20th
Century, maternal health programmes were
driven largely by a perceived shortage oflabour needed to work on plantations and inexport industries (De Barros, 2014; Thomas,
2003). Perspective shifted to promoting
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smaller families were seen as more conducive
to national economic development and global
security, and also as leaders and internationalorganizations reacted to fears of an impending“population bomb” exploding in developing
countries (UNFPA, 2023b; Bourbonnais, 2016;
Solinger and Nakachi, 2016; Ahluwalia, 2008;
Connelly, 2008; Klausen, 2004; Briggs, 2003;
Hartmann, 1995). Notably, instrumentalist
rhetoric around childbearing persists today,
both in fears of “overpopulation” in a context
of climate change, which can attributeenvironmental destruction to fertility rates
among people in the Global South, and in fears
of “underpopulation” when it comes to ageing
societies (UNFPA, 2023b).
For these reasons, the field of reproductive
health bears particularly deep scars from theworld’s racialized colonial history. Slavery
institutionalized Black women’s loss of bodily
and reproductive autonomy and incentivized
control over enslaved people’s ability toreproduce (Johnson and others, 1999). For
many Black women, reproduction was an areaof control and exploitation, including rape,
forced sterilization, medical experimentationand non-consented medical research andtraining. One of the most well-known examples
is the case of J. Marion Sims, a gynaecologist
who performed experimental surgeries on
enslaved Black women without anaesthesia or
their informed consent (Owens, 2017) – butin fact this was far from an isolated incident.
Slave hospitals of the era primarily facilitatedthe production of biomedical knowledge about
Blackness and normalized the idea that Blackbodies were physiologically distinct, inferior
and impervious to pain (Hogarth, 2017).

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In this way, advances in obstetric andgynaecological medicine have contained aninherent contradiction for some of the mostmarginalized women and girls – these fieldsof medicine are comprised, on the one hand,of knowledge and technologies that can save
lives and alleviate suffering, while on the other
hand emerging from, and even perpetuating,significant harms. This duality played out, aswell, in the advent of modern contraception,
which was revolutionary for women’s bodily andreproductive autonomy yet was also promoted
as a tool for the application of eugenics
theories. Modern fertility control was widelyseen, including by its earliest proponents, asa means with which to curb the reproductionof “undesired” populations, particularly poor
women, women with disabilities, Black women,
women of marginalized ethnicities in the Global
South, and indigenous people in the Global
North (Ross and Solinger, 2017; Ginsburg andRapp, 1995). The use of contraception as a tool

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for reproductive control persisted for decades.
In apartheid-era South Africa, for example,
Black women were often subject to aggressive
contraception programmes, which were carriedout under the guise of population control(Klugman, 1993).
Black women living under South Africa’s
apartheid regime were also more likely toexperience obstetric violence and mistreatmentin the health-care system. Non-consented careand obstetric violence were particularly notedin public hospitals serving predominantly
low-income communities, where multiple
marginalizing factors – gender, poverty, race –coalesced. These populations endured lack of
informed consent, lack of awareness ofpatients’ rights, and lack of training
for health-care providers on how to

obtain informed consent and provide respectfulcare (Jewkes and others, 2015).
Subpar treatment of Black people and otherdisadvantaged persons within the medical fieldcontinues to this day (UNFPA and others,2023). For example, international human rights
bodies have repeatedly expressed concern about
the persistent discrimination and human rights
violations facing Roma women, particularly in
reproductive health care (Committee on the
Elimination of Racial Discrimination, 2017;
Human Rights Committee, 2016; Committee
on the Elimination of Discrimination against
Women, 2015). A 2020 report by the European
Roma Rights Centre on reproductive rightsof Roma women found that numerous
interviewees had been immobilized duringchildbirth, subjected to physical abuse anddenied anaesthesia (ERRC, 2020). This legacy
also persists in ongoing health disparities among
Black and ethnic minority women in the United
Kingdom (MBRRACE-UK, 2020) and UnitedStates (Hoyert, 2023), and among migrants andmembers of certain castes in India (Allard andothers, 2022) and other South Asian countries(Kapilashrami and John, 2023).
But a positive development can be found in
the increased attention, and growing bodyof evidence, on discrimination and harm insexual and reproductive health settings (Downe
and others, 2023). These findings note that
discrimination is linked to the normalizationof harm, and that it is often invisible to healthpractitioners, health systems and even patientsthemselves. “Where violence is an everyday, andeven trivial, ‘fact of life’... it becomes expected,
invisible, and, therefore, structurally embedded,”researchers note. Furthermore, efforts to50

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3/28/24 11:15 AMreduce or eliminate violence are ineffective whendiscrimination and stigma are not addressed(Bohren and others, 2022), an observation that
can also be seen as a call to action to root out bias
in health-care spaces.
These findings can, and should, be applied inhealth systems writ large, where inequities in careare racialized or can be attributed to ethnicity,

cultural differences, migration status or formsof marginalization. To address disrespectful andabusive treatment of women during childbirth,for instance, WHO has called for action –including research, human rights alignment andgreater participation by women from affected
communities – to be taken by governments,
health-care providers, professional associations
and educational institutions (WHO, 2015).

Forced sterilization – an ongoing violation
While quality sexual and reproductive health care contributes to – and is supported by – individual
empowerment, the reverse is also true. Substandard or poorly tailored sexual and reproductive health care,denial of services and violations of reproductive rights can result in a cascade of harms across one’s life,and disadvantages reciprocally contribute to vulnerability to substandard care, denial of care and rights
violations. Perhaps nowhere is this more pronounced than in the case of coerced sterilization, one of themost extreme forms of control over a person’s reproductive autonomy. By permanently denying women
the right to have children, non-consensual sterilization enforces society’s view that certain women do notdeserve to be mothers. Black women, indigenous women, women from religious minorities, women livingwith a disability, institutionalized women, migrant women and impoverished women in rural settings haveall been subjected to sterilization abuse (Roberts, 1991), both historically and today. In 2015, for example,
a complaint was lodged with the Commission for Gender Equality on behalf of 48 South African women
who had experienced forced or coerced sterilization in public hospitals. All were pregnant Black women,
and most were HIV-positive. They described being coerced or forced to sign consent forms that allegedly
permitted sterilization while they were in extreme pain or active labour. The Commission found that thecomplainants’ rights to equality, freedom from discrimination, dignity, bodily integrity, freedom and security
over their bodies, and the highest attainable standards of health, including sexual and reproductive healthand rights, had been violated (Commission for Gender Equality, 2020). In another example, a 2022 reportto the Human Rights Council highlighted that forced sterilization is a common practice around the globe(United Nations General Assembly, 2022).

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FEATURE

Grass-roots activists raise
visibility for missing and murderedindigenous women
Although Carolyn DeFord’s motherdisappeared in 1999, it wasn’t until
2011 that she ﬁnally learned theterm to describe the complicatedgrief she had felt since that day:ambiguous loss.
“You’re stuck, and you can’t moveon, and there’s the constant wonder,”says Ms. DeFord, who is a memberof the Puyallup Tribe in Washington
State and board member of Missingand Murdered Indigenous Women
USA (MMIWUSA). “I’ve imagined
everything that could have happened
to my mum, in every way, over andover again.”This lack of closure is experienced
by thousands of indigenous people
across the United States whose
relatives are reported missing
every year. The murder rate for
Native American women living on
reservations can be up to 10 times
the national average (Urban Indian
Health Institute, 2018), making
murder the third leading cause ofdeath for Native women. Though
the statistics are stark, there arehuge gaps in data, meaning thatthe numbers affected are likely

52

underestimated. In 2016, theNational Crime Information Center
reported 5,712 cases of missing
American Indian and Alaska Native
women and girls; in the same year,
the US Department of Justicerecorded just 116 cases in its
missing persons database.
Underreporting of cases,
racial misclassiﬁcation andpoor relationships between
law enforcement and Native
communities all contribute to
the lack of reliable data (Urban
Indian Health Institute, 2018). A
jurisdictional web exacerbates the
problem. In 1978, the US Supreme
Court ruled that tribal nations could
no longer prosecute non-Natives
who commit crimes against Native
individuals on tribal lands. As aresult, when an indigenous personis the victim of a violent crime, theNative or non-Native identities ofthe victim and perpetrator(s), thelocation of the crime either on or
off the reservation, and the natureand severity of the act must all beestablished before it is even known
which authorities should handle
the case.

Many believe perpetrators havebeen able to take advantage ofthe confusion to target indigenous
women and girls. “We need to beable to have jurisdiction over crimes
committed on our land. We’renations within nations, sovereign
nations within a nation, and wehave the least ability to protect ourpeople,” Ms. DeFord says.
Families of missing persons andNative advocates say even wheninvestigations are conducted, they
are not afforded the rigour they
deserve. “It feels like everybody’s
trying to pass the buck so that
nobody has to get their hands
dirty,” says Ms. DeFord. “That’s
probably not the case, but it’s what
it feels like.”
In 2013, the reauthorization of
the Violence Against Women Act(VAWA) restored tribal criminal
jurisdiction over non-Native
individuals committing crimes ofdomestic violence on tribal lands.
The most recent reauthorization,in 2022, expanded the list of crimes
that could be prosecuted to include
sexual violence, sex trafﬁcking

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and stalking, among others. Luhui
Whitebear, a professor of Indigenous
Studies at Oregon State University
and board member with MMIWUSA,
says tribal nations now have accessto a new range of tools to protect
their communities from harm. Still,
she says, legal reforms only go sofar. “People think ‘Yes, we did it!’
But that’s not always the end of
the story.”
Prof. Whitebear points out thatthe 2022 VAWA reauthorization
doesn’t cover all tribal nations –only federally recognized ones.
This means that nations like
Prof. Whitebear’s own, the Coastal
Band of the Chumash Nation, arenot covered by the act. There is also
the issue of resources, with tribes
rarely having access to sufﬁcientfunding or training to conduct
thorough investigations.
Grass-roots organizations like
MMIWUSA are stepping in to help.
Often, what families need mostwhen a loved one goes missing
are basic things – a plane ticket,
feet on the ground to conduct asearch, or money to hire a babysitterfor children whose parent has
disappeared. “I’m really thankful that
there are people who are dedicating
so much time to doing groundsearches for people and creating
missing ﬂiers, because sometimes
families have to choose, ‘Do I eat
dinner, or do I look for my missing
person? Because I don’t havesupport for a search.’ And so for

Carolyn DeFord, whose mother disappeared in 1999, works with MMIWUSA to advocate
for the rights and well-being of indigenous women and girls in the United States. Image
courtesy of Carolyn DeFord

organizations to be able to provide
resources for those searches iscritical,” says Prof. Whitebear.
Another crucial step is ending
stereotypes of indigenous people
and communities. “De-normalizingthat exploitation of people’sbodies and the view of us asdisposable would help immensely,”
Prof. Whitebear says. “I would saythat what helps to end violenceagainst indigenous women is viewing
it as not just an indigenous issue.
This is everyone’s issue.”
For Ms. DeFord, in the years since
her mother disappeared, she haslearned to take her grief and use
it to help other families struggling
for answers: “It’s been very healing
to share my story, to be able to use

my experience to help other people,
like these other advocates are
helping me,” she says. “Being able
to do some of that footwork so thatfamilies can take care of themselves
and be where they feel the mostuseful – that’s been helpful, really
being able to feel like this horrible,
traumatizing experience hasn’t been
in vain. If I can use that to help otherpeople, then it makes me feel like atleast there’s a purpose.”
Local advocates are also helping
to reshape laws. “Some of theﬁrst legislation in the country was
passed here,” says Ms. DeFord,“and it was because of grass-roots
voices, because of families going
and testifying and sharing ourstories and our frustrations andwhat we needed.”

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The legacy of misinformation
Despite the progress seen within medical
science and in international human rights
agreements, falsehoods and assumptions
remain widespread, permeating not only social
norms and domestic laws but also health andeducation systems. As a result, these vestigial
misconceptions continue to enact harm.
Many of these misconceptions rely on an
overly simple understanding of human sexual
development. When sexual development,
traits and identity are assumed to follow
one standard pathway, natural variation in
the human experience may seem wrong or
disordered, and people who fail to conform to
expectations may find themselves unserved oreven harmed by policies and practices.
As one example, menarche – the onset of
menstruation – was once widely believed to
be a biologically incontrovertible sign of agirl’s readiness for pregnancy. The ability to
menstruate was assumed to indicate fertility
and the ability to bear children. A girl’smarriageability could be socially or legally
determined by whether or not she had
menstruated. As recently as the 1970s, one
internationally used gynaecology textbook
taught that menstruation was “the weepingof a disappointed uterus” (Jeffcoate, 1975),
implying that menstruation signals the failureof a female body to become pregnant.
Perspectives about menarche have evolved overtime, and contemporary views recognize amore comprehensive understanding of physicaland emotional maturity. Today it is known
that many early menstrual cycles are notaccompanied by the release of an ovum, and54

therefore menarche does not necessarily signalthat pregnancy is possible (Carlson and Shaw,2019). Age of menarche also changes basedon factors such as genetics, nutritional status
and exposure to environmental pollutants(Forman and others, 2013), and mental andpsychological maturity are now understoodto take place years – even a decade – after the
average age of menarche (Arain and others,2013). Pregnancy and motherhood in earlyadolescence are now understood to pose
life-threatening physiological and mental
health risks.
Yet rather than teach that menarche is
one factor among many in the process ofdeveloping fertility, it continues to be taught
as signifying one’s body is “prepared” forpregnancy. This oversimplification can beused to support incorrect beliefs, such as
the notion that younger adolescents do not
require education about menstruation or thepresumption that pregnant adolescents are
physiologically equipped for childbirth.
Another oversimplification involves genderessentialism – the outdated idea that men andwomen are distinct biologically, physiologicallyand in their innate capacities, and that thesedifferences are unchangeable (Meyer andGelman, 2016). Researchers across multiple
disciplines have discredited this notion:“[E]vidence include[s] neuroscience findingsthat refute sexual dimorphism”, i.e., theexistence of two distinct and fixed categories,“suggesting that the tendency to view
gender/sex as a meaningful, binary category
is culturally determined and malleable”(Hyde and others, 2019).

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The reality is much more complicated, for both
sex and gender, terms that are often conflated
but that carry different meanings. Sex, referringto the biological and physiological characteristics
of females and males, such as chromosomes,
hormones and reproductive organs, is often seen
as falling into only two categories. Yet studies
estimate that roughly 2 per cent of people
actually have intersex variations (with somefigures as high as 4 per cent [Jones, 2018]),
meaning they have anatomy, chromosomes,
hormones or other physical traits that do not
fall perfectly within the male-female dichotomy.

Gender, on the other hand, can be describedas the socially constructed characteristics ofwomen, men, girls and boys, and the processof conforming to these social expectations
through norms, behaviours, roles and othermeans (WHO, n.d.). Gender, too, defies
duality – communities from countries aroundthe globe (including Argentina, Australia,
Bangladesh, Canada, Fiji, India, Mexico, Nepal,
New Zealand, Pakistan, the Philippines, Samoa,
Thailand, Tonga and the United States) recognize
identities that do not correspond with the male/
female binary (OHCHR, 2023a).

When gender expectations are a moving target
While many people born with non-dimorphic sex traits are forced by legal, social and health systems to ﬁt
within the gender binary, those who do live within the gender binary often face scrutiny, stigma and exclusion
for failing to embody those gender norms enough.
Elite South African runner Caster Semenya was both assigned female at birth and has continuously
identiﬁed as female, but her femaleness has been repeatedly questioned by athletic competitors andinstitutions, a situation common to women and girl athletes perceived to be too masculine. Ms. Semenya
was coerced into undertaking hormone treatments to “correct” her natural body. She continued to winraces during hormone treatment, but felt tired, nauseous and as though, she said, “I had been running in abody that wasn’t my own” (Semenya, 2023). She has also been subjected to repeated invasive sex testing,a violation of a range of internationally protected fundamental rights. The human rights court of Europe
recently ruled that her right to freedom from discrimination and private life had been violated (European
Court of Human Rights, 2023), yet she remains barred from participating in athletic events by the World
Athletics governing body (Reid and Worden, 2023). And she is just one of a number of world-class women
runners (many from developing countries) who have been banned from competition, pressured into
surgeries and/or subjected to genital examinations, all because their naturally occurring sex traits are
considered unacceptable by athletics authorities (Longman, 2024).

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There is nothing inherently political orideological in acknowledging the existence ofgender diversity, or in noting the prevalence of
non-dimorphic sex traits. This complexity does
not require eliminating the categories “men”
and “women”. Indeed, the global consensus onachieving gender equality requires that harms
overwhelmingly associated with men and boys orwith women and girls be identified as such. But
harms overwhelmingly associated with people
who do not conform to sex or gender binaries
must also be identified accurately, or else theseharms will persist – and they are significant. The
Office of the High Commissioner for Human
Rights notes that intersex people are subjected
to infanticide; forced and coercive medical
interventions; discrimination in education, sport,
employment and other services; and lack ofaccess to justice and legal recognition (OHCHR,
n.d.a). People of diverse sexual orientations
and gender expressions, including lesbian,gay, bisexual and transgender people, also facerampant discrimination and violence, including
violence both legalized and enforced by States(OHCHR, n.d.b). The non-recognition of sexual
diversity – such as denials that sexual diversity
exists and refusal to collect data on sexual
minorities – does not, and cannot, eliminate thisbrutality and exclusion.
Misinformation about anatomical differences
based on race also remains deeply rooted in
education systems, including medical education
systems. For example, many contemporary
midwifery and obstetrics textbooks continue
to use the pelvic-shape classification proposed
in 1938 by W.E. Caldwell and H.C. Moloy,
doctors who believed certain pelvic shapes
were “ultrahuman” – the perceived standard for56

human development – while others represented
an “arrest in evolution from the ape form”.
Today, researchers note, “There is good evidence
that the shape of the birth canal is highlyvariable and tends to differ both within andamong human populations, and that using thegynaecoid shape as a model for all women is
empirically unsupported, factually inaccurate
and potentially dangerous, especially for womenof non-European ancestry” (Betti, 2021).
Similar misconceptions affect access to pain
relief and other care. One study from 2016
in the United States found that about half ofparticipating medical students and medical
residents endorsed at least one false belief about
biological differences between Black and white
people, such as that Black people have lesssensitive nerve endings, thicker skin or higher
fertility (Hoffman and others, 2016).
As a final example, misconceptions about
history are also pervasive, with ongoingconsequences for access to services that should
enable bodily autonomy and sexual andreproductive health. For instance, many popularnarratives suggest that the advancement ofsexual rights and abortion rights internationallyare forms of Western influence (OHCHR,
2023a). In fact, a great deal of evidence points
to colonial regimes enacting and enforcing
homophobic norms and laws and restrictions
on women’s bodily autonomy (see spread on
page 60). Often, these norms and laws remain
in force after countries achieve independence
from colonial control, even in cases where
precolonial cultures were comparatively
open to diversity in gender expression andsexual orientation.

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New understandings embraced in health systems
Health experts now widely accept that menarche is not the deﬁning marker of womanhood, and that
racial assumptions about pain and pelvises can cause harm. Health systems are also increasingly
recognizing diverse gender identities, sexual orientations and sex characteristics as being within
the spectrum of normal human development. For example, over the past three decades, many traitsof sexual minorities once believed to be pathological have been recategorized as non-pathologicalor otherwise removed from diagnostic codes. This is not simply an effort to better realize humanrights; it is also a reﬂection of the “poor-quality evidence and social rationales that justiﬁed”
these diagnoses to begin with (Carpenter, 2018). This move is also coherent with global efforts
to improve public health overall through destigmatization (UNAIDS, 2021) and through growing
awareness that health services must be tailored to populations that are far more diverse thanpreviously acknowledged.
Still, some States are considering measures that entrenchpathologization and intervene in rights-afﬁrming health care. In 2021
in Guatemala, draft legislation, which ultimately did not pass, sought
to protect children from the “disorder” and “trauma” of transgender
identity, and policymakers in Ghana are considering drafting
legislation that promotes practices of so-called “conversion therapy”
by offering incentives to transgender persons who “recant” (OHCHR,2022). In the United States, in 2023, 87 anti-trans bills were passed,out of some 600 proposed at the local, state and federal levels,
including bills that penalize
health-care workers for referringor providing gender-afﬁrmingcare to transgender people(Trans Legislation Tracker, n.d.).

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A bridge to a better future
Reconciling modern health systems with theselegacies need not be painful or punitive. As thehistory of the ICPD shows, there is a globallyagreed common agenda to secure gender equality
and sexual and reproductive health and rights for
all people. The benefits of this common agenda
are felt individually, in human rights realized,
higher standards of health attained and humanpotential expanded, and they are felt acrosscommunities, societies, nations and regions. To
reach these agreed goals, a concerted and wellfunded effort must be made, not to push down
those who have already felt the gains of progress
but to raise up those who have yet to accessthose gains.
It should not be controversial to note that many
medical and societal advances have been enabled
by a long history of health-system mistreatment,from the invention of tools like the Sims
speculum to eugenics motives that ultimately
played a role in expanding access to familyplanning. And it should not be controversial torecognize that the descendents of those who were
mistreated continue to endure some of the mostattenuated access to these services, technologies
and rights.
Indeed, it is urgent that we learn from past
mistakes. Reproductive health technologies
continue to advance rapidly, creating
opportunities both to benefit individuals and to
perpetuate abuses (UNFPA, 2024b). Valuable
diagnostic tools like prenatal testing are alreadycommonly misused for gender-biased sex
selection, for example. Users of powerful new
digital technologies are already giving away
access to deeply private data, often without

58

knowing it. And on the horizon are artificial
intelligence-boosted diagnostics, cytoplasmictransfers that could produce embryos with threeparents, in-vitro gametogenesis that can produce
sperm or egg cells from non-reproductive cells– innovations that could change the nature of
reproduction, sex and family configuration –and many more advancements. The potential
for serious harm, including issues of patient
safety and privacy as well as “ethical and humanrights concerns about the commodification ofhuman reproduction”, exists, as always, alongsidesignificant positive gains (UNFPA, 2024). As
much as these technologies could be used to
mistreat or exclude marginalized groups, they
can also be tools of inclusion and empowerment,
for example by expanding quality sexual andreproductive health services to those who are
currently beyond reach, and by enabling genderdiverse individuals and people excluded frominfertility treatment services (Perritt and Eugene,2022) to create the families of their choosing.
Movements around the world are helping us
reconcile with the ills of the past, efforts that can– and should – inform our vision of the future.
Global donors are targeting some of the most
severely left-behind communities for investment
in midwifery, gender equality and comprehensive
sexuality education initiatives (see page 108).
Increasing inclusivity in medicine and research
is improving the quality of human knowledge.
We have a much better understanding today
of diversity in gender expression, how gendernorms vary within and between countries andhow complex and diverse sex traits are. We havea much better understanding of how women ofcolour, indigenous women and women in the
Global South have been excluded from much

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of the progress seen in sexual and reproductive
health and rights.
This report’s analysis of barriers to health care,as reported by women themselves (page 28),
finds that progress is indeed possible, and thatwhile, in general, those groups of women who
faced the highest prevalence of barriers to healthcare have experienced the least progress, they
did experience progress. And in some countries,
the strongest improvements in health-care accesswere among ethnic groups that had previously
experienced the worst levels of self-reported
barriers to care – heartening indications that
progress can indeed be accelerated. And whilemuch more evidence is needed to design policies
and programmes that reach all people (seeChapter 3), the clarity of insight into inequity
and, therefore, the possibility of achieving realjustice has never been greater.

Bilums are tote bags used in Papua New Guinea. People use them as baby carriers – “bilum” translates to “womb” in the Tok Pisin
language – and for transporting goods to market, as well as in the funeral ceremonies of prominent community members. In this way,bilums accompany many Papua New Guineans throughout life. This pattern, the skin pig design, represents the struggle of women to
be seen, heard and respected. © UNFPA Papua New Guinea/PidginProductions

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I N FOCUS

Decolonizing sexual and gender norms
In July 2023, the United Nations
Secretary-General released areport drawing attention to therole of colonialism in perpetuating
violence and discrimination
against gender-diverse populations(OHCHR, 2023a). The report, by the
Independent Expert on Protection
from violence and discrimination
based on sexual orientation andgender identity, drew from hundredsof meetings, visits and exchanges
with State and non-State actors fromaround the world. The cumulative
evidence found that speciﬁc
strategies to exercise control overcolonized persons – employed bydiverse colonial powers – resulted
in the stigmatization, criminalizationand pathologization of same-sex
attraction, transgender identities
and other forms of diverse
gender expression.
Precolonial diversity
From the Filipino indigenous
community’s babaylan spiritual
protectors to ogbanje individualsin Nigeria, diversity in sexual
orientations and gender identities
has existed everywhere throughout
recorded history. Individuals
embodying gender-variant identities
have been cherished and respected
in many societies, such as the “twospirit persons” in North America,
the bonju in Europe, the muxes

60

in Mexico, the hijra in India and
Bangladesh, the takatāpui in New
Zealand and the “sistergirls” of the
Aboriginal and Torres Strait Islander
peoples in Australia.
Indeed, the social meaning attached
to sex characteristics is as varied
as cultures around the world.
Patriarchal and heteronormativesocial structures certainly existed
in many precolonial societies, butthere is also ample evidence of
normalized gender variation inothers. Some communities evenhad dedicated roles for people
with diverse sex and gendercharacteristics, including positions
as advisers, military commanders,royal court members, healers andkeepers of traditional practices.
Colonial control strategies
While recent colonial projects
did not invent gender-binary
norms, they did result in thesystematic imposition of agender binary through laws andpractices that affected colonizedpeople over centuries of control.
Colonial strategies included
the conversion of colonizedpeople to religious institutions,the criminalization of genderand sexual nonconformity
and the enforcement of rigidsocial hierarchies.

Both religious and secularjustiﬁcations were given for the
moral codes enforced by colonial
powers. Examples include “pecado
nefando”, or the crime of “nefarioussin”, applied by Portuguese andSpanish inquisitorial courts; Frenchlaws criminalizing “lewd or unnaturalacts”, which were intended toinculcate colonized people with
Christian morals; and Britishcolonial laws punishing “grossindecency” between two men. Other
laws included “sodomy”, “buggery”,“carnal knowledge against the orderof nature”, as well as offencessuch as “public indecency” and“encouraging debauchery”. There
were also “vagrancy laws” that
did not directly restrict sexual or
gender-divergent conduct, but which
had a disproportionate impact on
people living in poverty, genderand sexual minorities and persons
with disabilities.
Notably, the same, or similar,
laws were applied within thesocieties of colonial powers.
Moments of “sex panic” or “moral
panic” took place within European
countries, for example, during
which governments, medical
authorities and the mainstream
media identiﬁed groups who did
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enforcement of these laws withincolonies was linked to policymakers’
perceptions – often based upon
reports of explorers – that same-sex
relations were pervasive across thecolonized world (HRW, 2008).
While the law was a principal meansof enforcement, it also formed
the basis for complex systems ofsocialization that included policing,
medicine, literature and education.
Black sexuality, for example, wasregarded as “rampant and insatiable,
and thus in need of regulation”(Westman, 2023). Indeed, in colonial
settings the ability to thrive washeavily dependent on a person’s
ability to assimilate to white,
patriarchal and heteronormative
customs.
Lasting impact
Colonial laws and norms have had
an impact well beyond current andformer colonies. In 1908, Thailand –which was never a European colony– adopted language from the Indian
penal code to ban acts “against
human nature”. In some cases,colonial dynamics have inﬂuenced
law and policy reform processes
even in post-colonial settings. For
example, Cameroon and Senegal,both former French colonies,
criminalized same-sex relations
after gaining independence in 1960.
Today, 64 countries still criminalize
same-sex consensual acts, often
referring explicitly to sexualintimacy between men; 41 countries

criminalize sexual intimacy between
women; and 20 countries explicitly
criminalize and/or persecutetransgender persons throughlaws targeting “cross-dressing”,“impersonation” and “disguise”.
And although many of the world’s
anti-LGBTQIA+ legal frameworks
originate from colonial legislationand social mores, today it isadvocacy of the human rights of
LGBTQIA+ persons that is often
portrayed as colonial or as aWestern agenda (OHCHR, 2023a).
One important step towards
realizing the rights of all people,
in all their diversities, is to reject
the view that the Global West or
North are archetypes of inevitable
progress, while framing the Global
South or East as backward. Ifanything, it is the persistence ofcolonial-era legal frameworks
and social norms, inheritedfrom the Global West and North,that continue to constrain theinternationally agreed human rights
of LGBTQIA+ persons, particularly
those living in the Global Southor East.
Further avenues for research
The above summary of the
Independent Expert’s reportnecessarily excludes the impact
of colonial laws and norms on
aspects of sexual and reproductive
health beyond gender and sexual
diversity. However, the ﬁndings raise
important related questions about
the legacy of colonialism on genderequality and sexual and reproductive
health and rights.
For example, there is evidence
that abortion was practised inmany precolonial communities,
but banned by colonial-era laws
(OHCHR, 2021b; Malvern andMacleod, 2018). In fact, European
colonial powers have been called“the most important sources” oflaws restricting abortion; suchlaws were in place in almost every
country in the world by the endof the 19th Century (Berer, 2017).
Similarly, obscenity, vice andindecency laws – many dating from
European colonial rule – were widelyused to prohibit information aboutfamily planning from the start to the
middle of the 20th Century (Stepan
and Kellogg, 1974). These and otherconsequences of colonialism on
women’s reproductive health andrights merit further exploration,
especially given the persistenceof reproductive health and rights
violations around the world.
This text was contributed by Victor
Madrigal-Borloz, who from 2018 to2023 served as the United Nations
Independent Expert on Protection
from violence and discrimination
based on sexual orientation andgender identity.

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STATE OF WORLD POP ULA TION 2024

CHAPTER 3

     

63

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The 1994 ICPD, and its resulting Programmeof Action, not only represented a momentof remarkable consensus around the value of
universal sexual and reproductive health andreproductive rights (Brown and others, 2019;
Sen and others, 2019; Corrêa and others, 2015),
it also represented a powerful call for better andmore transparent data – a contribution to global
standards that has seldom been recognized.
In fact, an entire chapter of the Programmeof Action, Chapter XII (UNFPA, 1994), isdevoted to the need for “valid, reliable, timely,
culturally relevant, internationally comparable
data”, including “gender and ethnicity-specificinformation”. It also called for research into theviews of less-empowered groups of people andthose in different cultural settings.
This appeal for data took place at a time whenlittle was actually known about men’s andwomen’s sexual and reproductive health or
the realization of their rights. For example,
reliable data – and in most cases any data –on maternal mortality for the vast majority
of countries were non-existent in the 1990s(WHO and others, 2001). At the time of the
ICPD, WHO’s most recent maternal mortality
estimates (already more than half a decadeold) were rough given that many countrylevel data were thorny with non-representative
samples and problems of under-recording(WHO, 1991). Even without a globallyagreed maternal mortality estimate for 1990,
the ICPD Programme of Action called
for a cumulative 75 per cent reduction inmaternal deaths between 1990 and 2015, andcommitted to narrowing maternal mortality
disparities “within countries and between
geographical regions, socio-economic andethnic groups” (UNFPA, 1994).

64

These goals gave rise to a follow-up process thatsaw routine collaboration between populationand health ministers, demographers, statisticians,
epidemiologists and human rights experts, as wellas the establishment of measurable health andrights indicators and subsequent collection ofrigorous data to track progress towards achieving
the goals of the Programme of Action (Snow andothers, 2015; United Nations, 2014; UNFPA,
1998). Since 1994, the quality and quantity ofmaternal mortality data have vastly improved, as
have the statistical methods used to estimate these
data. By 2014, missing data had gone from being
the norm to being the exception, even as the bar
for what constitutes reliable data had been raised.
Thirty years after the ICPD, the world is at
another inflection point, with a similar goal
required, one which again recognizes vast andunacceptable unmet needs, even as we lack thedata to precisely define the scope of the problem:the ambition to meet the sexual and reproductive
health and rights of those individuals who
have been left – and pushed – behind, notonly by advances in health and the expansionof health infrastructure, but also by the data
revolution itself.
This chapter explores most closely the issueof maternal mortality, for which numerous
unanswered questions about levels and trends
globally, regionally, nationally and subnationallyremain, despite the steady advances in statisticalprowess and data availability. But maternal death
rates and ratios are only a starting point; beyond
the issue of maternal mortality are many further,still unanswered, questions about the health andrights of women and girls who continue to see
little of the progress experienced by their moreprivileged sisters.

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A new inflection point
Part of the story, and one that has been apparent
for some time, are the vast and – in many cases– growing inequalities in sexual and reproductive
health and rights. An expanding body ofevidence makes clear that some individuals arepushed to the margins of societies and healthsystems – those facing discrimination in healthsystems, those with language barriers in clinicalsettings, those stigmatized for their HIV status,
or unreachable because they lack the privileges ofcitizenship, as only a few examples.
The available data strongly indicate these
individuals are suffering and dying in far greater
proportions than previously imagined (Khaliland others, 2023; Geller and others, 2018;
Gon and others, 2018). Yet their deaths – andthe morbidities and indignities that precede
these deaths – are largely invisible (Creanga
and others, 2014). Why? Deaths and injuries
remain uncounted because of deficient datasystems, infrequent surveys and other studies
that are limited in scope or comparability.
When their deaths and morbidities arecounted, the underlying inequalities are often
invisible because few efforts have been made todisaggregate data by the particularities of their
exclusion. Their disproportionate experience of
injury and death is absorbed into the vastness ofstatistical averages.
When this veil is lifted, we see gaping
inequalities both between and within countries.
One common public health explanation is theinverse equity hypothesis, in which new healthinterventions are most immediately adopted
by wealthier populations that have the lowest
levels of need (Victora and others, 2018).

Crying Women by Bayombe Endani, Democratic Republic of the Congo, 2010.
Artwork contributed by the Advocacy Project, which helps marginalized
communities use embroidery as a tool for therapy and advocacy.

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Health advancements can therefore give riseto an initial increase in overall inequality –with inequality declining if and when thoseadvancements become accessible to those withgreater needs. Yet by some measures, inequalities
both between and within countries are growing.
In 1990, for instance, a 15-year-old girl had on
average a 1 in 12 chance of eventually dying
from pregnancy or childbirth in the 10 per centof countries with the highest risk, while a15-year-old girl in the 10 per cent of countries
with the lowest risk had a 1 in nearly 7,000
chance (see technical note). By 2020, girls in
the countries with the highest risk had a 1 in
34 chance of dying, while girls in the countries
with the lowest risk had a 1 in nearly 23,000
chance. This is a 2.8-fold change in the highestrisk countries, compared to a 3.3-fold change inthe lowest-risk countries – a widening inequality.
In other words, at the global extremes, progress
was greater where maternal mortality was rarest
and more limited where maternal mortality
was highest.
Such inequalities between countries are often
attributed to disparities in resources – but
this explanation falters when looking at theinequalities that exist within countries. These
intranational discrepancies make clear thatpersistent forms of discrimination and exclusion,
not just limited resources, play a significant rolein many of the global inequalities in sexual andreproductive health and rights that we see today(UNSDG, n.d.).
This is true both in countries where maternalmortality remains painfully high (Patel andothers, 2018; Acharya and Patra, 2017) (seetechnical note on page 155) and also in high-66

income countries where maternal mortality
is dramatically lower. Take the United States
and the United Kingdom, for example – 2 of
only 19 countries estimated to have a higher
maternal mortality ratio in 2020 than in 1990.
In both countries, the incidence of maternal
death is multiple times higher for Black
women than white women. The latest United
Nations estimates, which differ slightly fromeach country’s national estimates, indicate theUnited States had a maternal mortality ratio of
21 per 100,000 live births in 2020 (WHO andothers, 2023). According to official national
statistics in the United States, in 2021, Black
women faced a mortality ratio more thandouble the national average (Hoyert, 2023).
Maternal mortality risk is also higher than thenational average for the country’s Hispanic
women (Hoyert, 2023).
Still, these trends in the United States
are part of a broader increase in maternalmortality across the board – meaning it has
been increasing for most groups of womenin the country, including high, middle andlow socioeconomic classes; women of all age
groups; and women of all races (Hoyert, 2023;
Singh, 2021) (see technical note on page 154).
By contrast, in the United Kingdom, where theUnited Nations estimates maternal mortality
stood at 9.8 deaths per 100,000 live births in2020 (WHO and others, 2023), researchers
have shown that the rising maternal mortality
ratio is largely attributable to increased death
rates among certain ethnic minorities andsocioeconomic classes. The highest levels ofmaternal death, and highest increases, havebeen among Black women as well as women
who are the most socioeconomically deprived(Knight and others, 2022).

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It would be all too easy to dismiss these findings
as stand-alone results from just two countries.
Yet these are among a very small number ofnations worldwide that even have data systems
in place to identify such differences (Smalland others, 2017) – meaning they are amongsome of the only places in the world wheresuch disparities are being made visible. In fact,
the United States’ efforts to identify racial
disadvantage in maternal mortality date backto the earliest WHO tabulations where it was
the only country to have any type of racialor ethnic disaggregation (WHO, 1991). The
United Kingdom has an impressive maternalmortality surveillance system, dating back to1952 (making it the world’s oldest), but it only
started identifying ethnicity in 1995 (Small andothers, 2017).

number of countries in the Americas where data
make this possible. Only 4 of the 35 countries
identify the race or ethnicity of the women
who die in childbirth, and only 11 collectother maternal health data broken down by
race (UNFPA and others, 2023). Canada, forexample, joins the United States and United
Kingdom as one of the few countries withworse maternal mortality ratios in 2020 thanin 1990 (11 per 100,000 live births comparedwith 6.9) (WHO and others, 2023), but it does
not collect racial data in maternal surveillance
despite evidence of race-based barriers to accessand utilization of maternal health care. It istherefore impossible to know whether increases
in the country’s maternal mortality over time
have been universal or concentrated among selectsubpopulations (Dayo and others, 2022).

A UNFPA report released in 2023 examined,
for the first time, indicators of maternal healthamong women and girls of African descentand those with other heritages across the small

Where data do exist, they point squarely at
persistent inequalities facing marginalizedgroups, not just among Black people and peopleof African descent but also among indigenous

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people (Paradies, 2016). A 2018 paper by
UNFPA, UNICEF and UN Women examined
the limited data available on the maternal
health of indigenous women and girls. Out of
80 countries examined, 16 had data, and acrossthese 16 low- and middle-income countries(Belize, Costa Rica, Ethiopia, Gambia, Guyana,
Indonesia, Kenya, Lao People’s Democratic
Republic, Mexico, Namibia, Nepal, Pakistan,Senegal, Sierra Leone, Suriname and VietNam), women from indigenous ethnic groups
were significantly less likely to benefit fromantenatal care, less likely to give birth under
the care of a skilled birth attendant, more
likely to give birth as an adolescent, andsignificantly more likely to die of causes related
to pregnancy and childbirth (UNFPA andothers, 2018). Research from other countries– looking at indigenous women in Australia(Australian Indigenous HealthInfoNet, n.d.),India (Government of India, Ministry of
Health and Family Welfare, 2016), Guatemala(ENSMI, 2015), Panama and Russia (Anderson
and others, 2016) – shows the same disparities.

Confronting the confounders
Evidence of racial inequities in health outcomes is often met with questions about possible
confounding factors: Could these disparities be the result of levels of education? Income differences?
What about employment factors or genetic predispositions towards ill health? The available researchon indigenous women and women of African descent shows that, while these characteristics domatter for health outcomes, they do not explain all of the disparities observed, meaning some or
many of these disparities are indeed linked to ethnicity (Australian Institute of Health and Welfare,2023). “Maternal deaths persist regardless of income and education levels, with maternal deaths
among African American college graduates still 1.6 times higher than among white women with lessthan a high school diploma,” recent UNFPA analysis found, as just one example (UNFPA and others,2023). Indeed, a growing body of research explores how chronic exposure to systemic injustice islinked to accelerated declines in physical health – often called weathering – that underpin many racialdisparities in maternal health (Geronimus, 2023; Forde and others, 2019). The analysis in this report(page 28) also supports this point: While there are signiﬁcant socioeconomic factors contributing
to self-reported disparities in health-care access, there are also considerable ethnic differences in
the proportion of women who have serious problems accessing care when sick, even controlling for
wealth, income, and urban or rural residence.

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Serious inequities are also apparent when
considering persons with disabilities. Women
with disabilities are up to 10 times more likely
to experience gender-based violence, including
sexual violence. And though young persons
with disabilities are just as likely to be sexuallyactive as their peers without disabilities, thispopulation faces significant barriers to accessing
sexual and reproductive health informationand services, including lack of accommodating
services and discriminatory attitudes among
health-care providers (UNFPA, 2018). Yet datacollection about the needs of this community
is also hindered by the stigma attached todisability, and by the lack of agreed definitions
when it comes to identifying persons withdisabilities and measuring their needs.
These issues are particularly troublesome giventhat roughly 1 billion people, 15 per centof the global population, are estimated toexperience a disability within their lifetime.
But important progress is taking place. In
2021, UNFPA found that the proportionof countries adopting standardized census
questions from the international Washington
Group on Disability Statistics “has increased
from 33 per cent in 2018 to 73 per cent in2020” (UNFPA, 2021b).

exist, they remain largely the product of ad
hoc efforts rather than arising from regular,
standardized national data systems such as
censuses or large-scale social surveys (European
Commission, Directorate-General for Justice
and Consumers, 2017). Furthermore, datacollection is hindered not just by stigma but by
the criminalization of same-sex sexual activity
and transgender identity and expression indozens of countries around the world (Human
Dignity Trust, n.d.). Finally, compounding
factors of exclusion, such as age, can create
extreme marginalization. For instance, recent
research points to how hostile laws and social
attitudes – including taboos against teenage
sexuality – mean that sexual and reproductive
health services and information (includingfrom LGBTQIA+ organizations) are all but
completely closed off to sexual- and genderminority adolescents in southern Africa(Müller and others, 2018).

Similarly, sexual and gender minorities also
face serious health disparities, not just inissues of access to and quality of health care,but in both psychological and physical healthoutcomes (Tabaac and others, 2020; Matsickand others, 2020; Caceres and others, 2019;
Gibson and others, 2018; Müller, 2016), yetdata remain limited. There are positive signs
that data collection on sexual and genderminorities is expanding, but where data do

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FEATURE

Women with disabilities in
Turkmenistan claim their rights
Years ago, at a gynaecologist’s ofﬁce
in Ashgabat, Turkmenistan, Alia
(name changed) and her husband
were advised that it was “undesirable”
for them to have a child because they
were both blind. “How will you be able
to take care of a child? How will you
raise them, watch them?” she recalls
being asked.
“They thought we wouldn’t be able
to cope at all and suggested having
an abortion,” Alia tells UNFPA. “But
I disagreed. My mother is blind, too,and she raised all seven of us.”
Alia’s experience is tragically familiar
among the one in ﬁve women
globally living with a disability.
Despite international agreements
guaranteeing people the world overthe freedom to make reproductive
choices free from discrimination andcoercion, women with disabilities
often face a different reality, one
in which prejudices drive healthprofessionals, intimate partners andthe public to question their capacity
to make sexual and reproductive
health decisions.

70

Research shows women and girls
with disabilities are frequently
confronted with discrimination
around reproductive choices, barredfrom health services by accessibility
issues and excluded fromcomprehensive sexuality education,
especially in special education
settings. And for some, that
discrimination can even translate
into forced sterilizations.
Like Alia, many have been judged
as ill equipped for pregnancy
and parenthood.
UNFPA research in 2021 foundthat many people with disabilities
in Turkmenistan were not able toaccess sexual and reproductive healthservices and information. To meettheir needs, UNFPA and the Society of
the Blind and Deaf of Turkmenistan
created sexual and reproductive
health videos accompanied by sign
language interpretation. The videos,available online and via ﬂash drives,
cover topics such as puberty, familyplanning and safe motherhood. Plans
for a mobile app are in the works.

Women reported the resources
taught them they could access
contraceptives and pregnancy
care free of charge. They also
appreciated the materials’
inclusion of contact information
for different clinics and service
providers. These steps and others
are making the country a more
inclusive and just place to bea pregnant woman living witha disability.
Still, Alia says more must be done:“It is necessary to increase theknowledge of medical staff sothat we are accepted and treatedlike everyone else.”
Meanwhile, she has embraced
parenthood while living with avisual impairment, like her motherbefore her. “I knew I could do it,”she says.

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Adopting a lens of equality
One of the great developments to take place
within the last 30 years has been an emerging
consensus that factors like gender, race,
ethnicity, disability status, sexual orientationand migration are not perks and penalties tobe tallied with a simple score. Rather, they are
dynamic factors at play within a complex webof advantages and disadvantages.
The last 15 years alone have seen a significant
shift in the world’s understanding of how
structural and intersectional barriers arepreventing certain people from realizing
their health and rights. For example, whereprevious research might have focusedsolely on individual behaviours – such as
delaying seeking treatment for an illness– that negatively affect health, researchers
today more readily acknowledge that thesebehaviours are shaped by broader norms,
systems and institutions, and also that multiple
intersecting factors can intensify the challenges
individuals face.
One groundbreaking study from 2009,
for example, compares the health-seeking
behaviours of poor women, non-poor women,poor men and non-poor men in India. The
study reveals that traditional methodologies
would mistakenly conclude that poor men andpoor women are equally disadvantaged, while
a methodology specifically designed to identify
the compounding influence of intersecting
factors of disadvantage reveals that poor men
were actually better off than all women – bothpoor and non-poor women. In essence, bothgender and class mattered for health outcomes,

but, in this case at least, men were able toleverage their gender advantage to such a
degree that even poor men were actually betteroff than non-poor women (Sen and Iyer, 2012;
Sen and others, 2009).
The interplay between forms of advantage
and forms of disadvantage greatly complicatesthe design of effective responses. A one-sizefits-all approach to policymaking simply
does not work. The past 30 years have seen
remarkable progress in part because policies
and interventions have elevated the welfareof the people most easily reached, those withthe least-complicated disadvantages, thosebest positioned to benefit. Reaching those
who remain in need, those with intersecting
vulnerabilities, will necessarily be harderand require more thoughtful interventions.
To continue apace with current approaches
creates the risks not only of inefficiency
but also of waste and harm. Information
circulated in languages that an intended
target does not understand, campaigns
that fail to account for cultural or religious
requirements of intended users, or clinics
inaccessible to people living with disabilities,
as just a handful of examples, result in lost
investments, continued exclusion and an
erosion of trust between health providers andthe populations they exist to serve.
But these findings are not cause for despair.
This new lens for understanding is something
to commend, even as it draws our attention
to uncomfortable facts about privilege andprejudice. Through this lens, we see moreclearly where efforts and resources are neededin order to achieve our global goals.

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Inequalities between and within countries:
the cases of India and Nigeria
For as long as measurements have existed, India andNigeria have been the two countries with the largest
absolute numbers of maternal deaths. Both in 1990
and in 2020, the countries together accounted formore than one third of all global maternal mortality.
India started the journey with many more deaths,
accounting for 26 per cent of all maternal deathsin 1990, compared to Nigeria, which accounted for
10 per cent. But by 2020, the countries had switchedplaces, with Nigeria accounting for 29 per cent of
all estimated global maternal deaths, while deaths
in India had fallen considerably – accounting
for 8 per cent of all worldwide maternal deaths(WHO, n.d.a).
While the pace of population growth plays a rolein these trends (Nigeria’s population more thandoubled between 1990 and 2020, while India’s
grew by a factor of 1.6), the core issue is thatmaternal mortality ratios have declined steeply
in India, but less so in Nigeria. India’s success isoften attributed to improved access to affordable,
quality maternal health services (Exemplars in
Global Health, 2023; Singh, 2018), as well as efforts
to address the impact of gender discrimination on
health outcomes. For example, one study found thatpolicies designed to address gender equality – suchas increasing the number of female physicians,
increasing institutional support and respect for
nurses, and promoting women’s empowerment
collectives — were associated with better healthoutcomes and increased health-care access for
women (Hay and others, 2019). Another study points
to how increases in the share of women in politics
were linked to increased numbers of primary andcommunity health centres, government dispensaries
and hospitals (Heymann and others, 2019). Other
effective programmes have promoted respectfulcare before, during and after delivery, and provided
free antenatal care.

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But this case study – of widening maternal healthinequalities between two countries – becomesmuch more complicated when looking at inequities
within these same countries. In both places, certain
groups of women are receiving the care theyneed while others are not. Dramatic differences inmaternal mortality are linked to locality in Nigeria,
for example, with signiﬁcantly higher death rates
among women in urban slums and rural locales, andhigher maternal death ratios in the north comparedto the south (Babajide and others, 2021; Gulumbeand others, 2018; Anastasi and others, 2017). Whenrelated vulnerabilities, such as child marriage andskilled birth attendance, are examined by ethnicity,
location and income, even more inequities are
revealed (UN Women, 2018). India, too, continues
to see dramatic inequities in maternal death risk.
Recent research into India’s 640 districts reveals thatwhile nearly one third of districts have achieved the
SDG goal of reducing maternal mortality ratio below
70 per 100,000 live births, 114 districts still haveratios of 210 or more deaths per 100,000 live births(Goli and others, 2022). The highest – 1,671 per
100,000 births – is seen in Tirap District of Arunachal
Pradesh, a rural area with a high proportion ofindigenous peoples. While disaggregating theseﬁgures by socioeconomic group, ethnicity, caste or
religion is challenging, these factors clearly play arole in health outcomes. For example, despite theentitlement of all women to free maternal health care
(Beckingham and others, 2022), women from themost disadvantaged castes and indigenous groups
receive less antenatal, postnatal and obstetric care,or none at all (Raghavendra, 2020; Yadav and Jena,
2020; Saroha and others, 2008). A central lesson inthese case studies is that all inequalities – including
those across countries and within countries –
require urgent attention, and that no one society or
region has yet achieved the goals towards which wecollectively aspire.

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Acceleration needed
The most recent 2023 estimates, using the best
available data and practices, hold that the global
maternal mortality ratio, as of 2020, had changed
little over the preceding five years – and was
tragically far from the goal set in 1994 (UNFPA,
1994). Critics might suggest this means the
1994 goal was simply unachievable, but evidence
from a handful of countries today indicates thatmaternal mortality ratios of 1 or 2 deaths per
100,000 births are indeed reachable (WHO andothers, 2023). What does this mean for the stateof maternal mortality today? Unfortunately, a
real-time view of progress in reducing maternal
death is currently impossible – not only becauseof limited data but also because official updates
only happen several years after the fact. As aresult, there is considerable uncertainty about thecurrent state of progress, especially in the wakeof the global COVID-19 pandemic. The mostrecent estimates contain data inclusive of only the
first year of the pandemic, a time in which experts
struggled to understand what proportion of total
COVID-19 deaths were also indirect obstetric
deaths (WHO and others, 2023). At present,
the full scale of the effects of the pandemic onmaternal outcomes remains unknown.
However, there are indications of distressing
increases in maternal mortality ratios in parts ofEurope, North America and Latin America andthe Caribbean. These increases are substantial andwidespread enough that they have offset declines
elsewhere, leading to stagnation in global maternalmortality ratios since 2016. Without more recent
data, it is not clear whether maternal deaths willrise further due to the impacts of the pandemic,
or if the recent increases have abated (WHO andothers, 2023).

Despite these mixed signals, there is hope in the
progress that has been achieved. First, the total
number of annual maternal deaths has fallen
considerably since 1994 – encouraging given thatthe global population has grown dramaticallyfrom 5.7 billion in 1994 to 8.1 billion in 2024
(UN DESA, 2022a). And second, the data arethemselves a sign of progress as well. With each
iterative improvement in data collection andanalysis, solutions present themselves – andsometimes in unlikely places.
For example, some estimates suggest that about
one third of the total reduction in maternalmortality is attributable to declining fertility,with the greater uptake of contraception
resulting in fewer pregnancies and safer spacing
between pregnancies (Snow and others, 2015).
Other research suggests that meeting the unmet
need for contraception can avert more than halfof maternal deaths simply because it will reduce
pregnancies at old and young ages when risk
is higher, increase the spacing between births
and decrease the likelihood of unsafe abortions(Utomo and others, 2021; Chola and others,
2015; Ahmed and others, 2012). Meanwhile,
the prevalence of unintended pregnancies andunmet need for contraception is plagued byinequalities across many factors, including age,socioeconomic status, race and ethnicity (Anikand others, 2022; Sully and others, 2020; Kim
and others, 2016), pointing the world to thecommunities that need to be reached.
Decades of data also underline the role of unsafe
abortion in contributing to maternal mortality.
This link was known as far back as 1987, when
the Safe Motherhood Conference highlighted
a finding from a study in Ethiopia wheremore than half of maternal deaths in Addis

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Measuring discrimination
With the Sustainable Development Goals, theinternational community has sought to measure the

FIGURE 4

Proportion of people experiencing discrimination, by
selected grounds, 2015-2023 (percentage)
 

proportion of people who have reported experiencing
discrimination or harassment in the previous
12 months, looking at forms of discriminationprohibited under international human rights law. These

 



 

data reveal that almost one in six individuals have



 



encountered discrimination within the past 12 months– and in certain settings, the number is as high as
one in three. The global prevalence of discrimination

is typically higher for women, and in certain societal
contexts women report discrimination up to threetimes more often than men. Similarly, individuals
with disabilities face discrimination nearly twice as  
¥ 

frequently as those without disabilities, with ratios ashigh as 6 to 1 in certain contexts.
Forms of discrimination
Racial discrimination*, rooted in factors such as
ethnicity, colour or language, is the most common
type of discrimination or harassment reported, witha median of 6 per cent of the global population
reporting discrimination on these grounds within thepast year. In extreme circumstances, this proportion
can reach nearly 24 per cent.
Intersectional discrimination compounds thechallenges faced by vulnerable groups, notably
women and persons with disabilities, who reportheightened discrimination based on their ethnic
origins, skin colour and linguistic afﬁliations. In somenational contexts, up to four times as many womenor six times as many individuals with disabilities
experience discrimination compared to men or
individuals without disabilities.
Discrimination based on age and sex each affects
a median of 4 per cent of the global population. In
certain regions, discrimination based on sex impacts
almost 19 per cent of the population, with signiﬁcantdisparities between men and women. For every man

facing sex-based discrimination, four women areaffected, and in speciﬁc country settings, this ratio
can escalate to as high as 1 to 20.
Age-related discrimination exhibits the highest
inter-country variation, with rates reaching slightly
above 34 per cent in some places. Limited
evidence suggests that younger populations report
disproportionately more age discrimination.
Progress and room to improve
Since 2023, there has been a 25 per cent increase in
the number of countries measuring discrimination – asigniﬁcant achievement. Still, there is much room toimprove: fewer than half of all nations systematically
capture and report the voices of those marginalized
by discrimination. Current data collection practices
also lack the granularity necessary for comprehensive,
disaggregated analysis of discrimination.
To address this challenge, the Praia Group is working
to develop governance statistics, including statistics
on non-discrimination and equality, and to promote ahuman rights-based approach to data.
This text was contributed by UN Human Rights.

¨ ©ª       

74

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Ababa were from infections following unsafe
abortions (Cohen, 1987). Now, the association
is well established: Unsafe abortion remains aleading cause of maternal death, accounting
for an estimated 1 in 13 of all maternal deaths
worldwide (Say and others, 2014). A growing
body of evidence shows that legal restrictions
do not lower the incidence of abortion andthat legal access to safe abortion indeed reducesmaternal mortality (Bearak and others, 2020;
Latt and others, 2019; Haddad and Nour,2009). Evidence also shows that restrictionsin abortion access are likely to deepen existing
inequalities in sexual and reproductive healthand rights (Fuentes, 2023; Harned and Fuentes,2023). The growing weight of these data may
contribute to the fact that more than 60 countries
have removed restrictions from their abortion
laws in the last 30 years. Still, today, about one
quarter of all women of reproductive age areliving in places where abortion is fully prohibitedor permitted only to save a woman’s life or under
specific circumstances such as pregnancy resulting
from rape (Center for Reproductive Rights, n.d.).

Inclusive Data Charter
In 2018, UNFPA joined a global network of governments, businesses, philanthropists and non-governmentalorganizations in launching the Inclusive Data Charter, a commitment to improve the quality, quantity,
ﬁnancing and availability of inclusive and disaggregated data. The charter is guided by ﬁve principles(Inclusive Data Charter and Global Partnership for Sustainable Development Data, 2018):
All populations must be included in the data. We can only achieve the “leave no one behind” goal by
empowering the furthest behind. This means ensuring their voices are heard and their experiences are
represented through data and analytics.
All data should, wherever possible, be disaggregated in order to accurately describe all populations. Datashould be disaggregated by sex, age, geographical location and disability status and, where possible, byincome, race, ethnicity, migratory status and other relevant characteristics.
Data should be drawn from all available sources. High-quality, timely data from ofﬁcial and non-ofﬁcial
sources should be accessible, and these should include new data sources, where consistent withinternationally accepted statistical standards.
Those responsible for the collection of data and production of statistics must be accountable. The
principles of transparency, conﬁdentiality and privacy must be balanced to ensure personal data are notabused or misused, in accordance with national laws and the Fundamental Principles of Ofﬁcial Statistics(United Nations Statistics Division, 2014).
Human and technical capacity to collect, analyse and use disaggregated data must be improved,
including through adequate and sustainable ﬁnancing. Collecting and analysing disaggregated datarequires speciﬁc skills and support.

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FEATURE

African censuses strive
to count everyone
After starting his career as aschoolteacher in the United Republicof Tanzania, Jonas Lubago went to
his local bank to open an accountbut was refused. The reason: He
was blind. The bank had a policy of
requiring any person with blindness
or vision impairment to bring adesignated proxy to sign for eventhe most basic transactions. That
was neither practical nor fair, says
Mr. Lubago.
Becoming a schoolteacher was
Mr. Lubago’s second choice. He
entered university with the intentionof studying law, but his academic
adviser discouraged him fromtrying because none of the required
reading existed in braille. “He toldme I would fail,” Mr. Lubago says.
That was two decades ago. While
the situation has improved over
the years, people with disabilities
in the United Republic of Tanzania
still face an array of obstacles when
they go about their daily lives orneed public services, such as healthcare and education. A clinic may
be right around the corner from the76

home of someone in a wheelchair,
but if it is accessible only by stairs,
or if the consultation rooms are too
small to allow the door to close forprivacy, or if the washrooms are notproperly equipped, that service is outof reach. “And that’s discrimination,”says Mr. Lubago, who is today thesecretary-general of the TanzanianFederation of Disabled Peoples’
Organizations.
In 2012, the country began
identifying people with disabilities
in its census. Still, the exercise
did not count a wide range of
disability categories nor did it
consider severity. “There was ademand for better data – both fromthe disabled community and fromthe Government,” says Principal
Statistician and National Census
Coordinator Seif Kuchengo.
The information gathered throughthe census is critically important.
As a State Party to the Convention
on the Rights of Persons with
Disabilities, the United Republic of
Tanzania committed to ensuring
and promoting “the full realizationof all human rights and fundamental
freedoms for all persons withdisabilities”. Yet institutions require
data in order to make services not
only available, but also accessible.
Mr. Kuchengo says ofﬁcials sought
early involvement of representatives
from the disability community
in the design of the most recent
census, including in the planningand in the training of enumerators.
Mr. Lubago, who left his teachingjob, joined forces with governmentofﬁces to have the census adopt
a more expansive and diverse setof internationally standardized
disability questions. In all, about
400 people with disabilities andimpairments were involved. Some
17 different categories of disability
or impairment were included,
and levels of severity could also
be speciﬁed.
Preliminary ﬁndings from a 2022
national census show that about
11 per cent of the population
has at least one type of physicalor developmental disability
or impairment, according to

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Mr. Kuchengo. That level is about
2 percentage points higher thanin 2012, but the increase is theresult of the recent census’s morecomprehensive approach to counting
people with disabilities. Mr. Lubago
hopes that new census data willshow just how large and importantthe disabilities community is, andresult in persons with disabilities
participating in local and national
decision-making.
In addition to generating betterdata on persons with disabilities,
the 2022 census also included
an innovative and more complete
count of nomads. Because thesecommunities are constantly on
the move in search of food, thegovernment had to reach out tothem well in advance to ensure theyremained in one place while thecensus was under way. This meant
making sure families had enoughfood to carry them through the twoday nationwide count.
The United Republic of Tanzania
is not the only country generating
better data on disabilities. Malawi’s
2018 census, for example, also
included albinism among its
disability parameters. People withalbinism experience multiple formsof discrimination and frequently facerisk of violence or death. Since 2006,
the United Nations Independent
Expert on the enjoyment of humanrights by persons with albinism
received close to 800 reports from28 countries of ritual attacks andAnastazia Gerald, a 23-year-old resident of Kahama, United Republic of Tanzania, is a trainedChampion living with disability with the My Choice My Rights programme, funded by theGovernment of Finland. The programme aims to accelerate progress towards fulﬁllment of
the rights of women and girls, particularly those with disabilities, and aims to contribute toending gender-based violence, female genital mutilation and child marriage. Photo © UNFPA
Tanzania/Ayubu Lulesu

witchcraft accusations against
people with this genetically inheritedlack of melanin in the hair, skin oreyes (OHCHR, n.d.c).
Deputy Director of Malawi’s
Demographic and Social Statistics
Department Isaac Chirwa says,“Many people have problems
walking around their communities
or even going to school because
they fear being attacked.” Before
the 2018 census, there were limited

data about how many people withalbinism there were or where they
lived, Mr. Chirwa explains, andwithout this information, it was
difﬁcult for policymakers to takeaction to make it safe for people togo about their lives and enjoy theirrights.

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Data as a human right
Data are not just for governments, forpolicies or for budgets. Data are for allof us, everywhere, to support our efforts
to understand, participate, make choices
and assert rights. Yet in many ways a data
lottery exists. The existence of the data
we need depends upon where we live.

78

While some factors – like gender, wealthor income, geography and age – areroutinely considered in surveys and analyses,
disaggregation by ethnicity, race, language,
religion or indigeneity remains quite rare.
Disaggregated data showing access toservices by HIV status, migration status or
LGBTQIA+ identity are even rarer.

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Disability was once rarely addressed, but theavailability of data in this area is increasing
rapidly. There are still gaps, however. For
example, monitoring of visible disabilities isahead of sensory disabilities, which are in turnahead of mental and intellectual disabilities.
Furthermore, there are individuals that theUnited Nations and major regional systems
almost never cover in data, such as people at riskof statelessness, internally displaced persons andprison populations. Sometimes their exclusion
is made explicit (for example, a population
survey might note that displaced people livingin camps or people detained in prisons havebeen excluded), but most often, their exclusion
remains invisible and unidentified.
Access to public information is a humanright, well established under internationallaw and many regional systems such as theAfrican Union, the Council of Europe and theOrganisation of American States (Article 19,2012). It is considered an enabling right, onethat allows other human rights to be fulfilled.
Furthermore, the right to information isessential to upholding rights to equality and tolife without discrimination. While some rights
violations can be established through a single
data point – the right to freedom from torture,for example, requires only one established caseof torture to show the right has been breached– identifying systemic discrimination requires
the collection and use of representative anddisaggregated data. Without these data, it is
impossible to determine whether laws, policies
and programmes, however ostensibly neutral,
result in discrimination.
This chapter’s focus on the insufficiency of dataon maternal mortality does not mean this is thesole need or focus. Rather it is one of many –too many – cases in which the absence of datameans the perpetuation of terrible inequalities.
For example, United Nations agreements have,since the 1990s, acknowledged the serious lackof data on gender-based violence, as well asof agreed measures of gender-based violence,
making monitoring impossible. It was not until

Data are for all of us, everywhere, to support
our efforts to understand, participate, makechoices and assert rights.

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Why are disaggregated data not collected?
Historically, many countries have claimed thatcertain population subgroups simply do notexist within their borders – and there may begood reasons for such claims, as stigma anddiscrimination often force people to hide theiridentities, making data collection extremely
challenging. But there are other reasons that
disaggregated data are not collected andpublished. Challenges include cost (Avendanoand others, 2018) and capacity, as well as
political sensitivity and risks (Backman andothers, 2008).
Disaggregating data indeed comes with acost. Achieving adequate sample sizes can be
expensive, for example. A survey that supplies
disaggregated data across many characteristics
may be very large or have elements that are
statistically less reliable. But there are ways
to keep expenses down. For example, Multiple
Indicator Cluster Surveys (MICS) are usually
carried out for an entire country, but special
surveys have been carried out exclusively among
Roma communities in a range of European
countries (e.g., North Macedonia and Serbia).
Such special surveys can reveal stark inequities.
For instance, a MICS in Kenya’s Turkana County
revealed that only about 26 per cent of Turkana
women gave birth assisted by a skilled attendant
while 84 per cent of women from other ethnic
groups did so (Kenya National Bureau of
Statistics, Population Studies and ResearchInstitute and UNICEF, 2016).
It is also true that certain kinds of data collection
can lead to abuse and misuse. For example,
the tracking of Jewish and Roma communities
facilitated genocide in many European countries
during World War II, and as a result many ofthese countries avoid ethnic identiﬁcation
today (Al-Zubaidi, 2022). Similarly, following
the genocide in Rwanda, the country has not
identiﬁed ethnicity in its Demographic and Health
Surveys, even though there are concerns about80

the persistent marginalization of populationsof indigenous forest dwellers (Ndikubwimana
and others, 2023; Collins and others, 2021). In
recent years, the use of religion and ethnicity
information on identity paperwork has been
linked to discrimination. In response to theseconcerns, the Ofﬁce of the High Commissioner
on Human Rights has published a guidancenote on a human rights-based approach tothe collection and analysis of data (OHCHR,2018), recommending that data be gatheredwith the active participation of disadvantaged
groups, that it be disaggregated to allow for
the understanding of differences between
groups, that members of groups be allowed
to self-identify, that data-collection processes
be transparent, that those responsible beaccountable, and that all data be conﬁdential,with the privacy of individuals respected.
Finally, some governments and institutions avoid
disaggregation because of fears that the data
will create or exacerbate political and social
tensions. They worry that data can be leveraged
by political opponents or critics of the current
authorities. However, avoiding collecting the data
does not make the inequalities less apparent in
the lives of those who are marginalized. In effect,
this calculus places political advantage above
the long-term development and inclusion ofdisadvantaged groups.
Not all risks will be present in all cases, and any
risks and costs should be carefully weighedagainst the potential beneﬁts in each case.
Choosing to not collect data can reﬂect alack of commitment to understanding andreaching the most marginalized and excluded,
or can suggest that leaders are putting shortterm political advantage above long-term
development and inclusion. As the Minority
Rights Group has asserted, “no data is data”(Thomas, 2023).

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2013 that WHO first published global andregional estimates for intimate partner violence
and non-partner sexual violence against women.
At the time, 79 countries had data. By 2019,153 countries had data (García-Moreno andAmin, 2019).
And in many cases, data still do not exist, or
exist in early form. SDG target 5.6.1 tracks the
proportion of women aged 15 to 49 years whomake their own informed decisions regarding
reproductive health care, contraceptive use
and sexual relations. This indicator is hugely
important – a first global attempt to measureand monitor bodily autonomy – but only about
one third of countries have official SDG data.
Analyses, based on data from 69 countries
for 2007 to 2022, suggest that just over half
(56 per cent) of married or in-union women
aged 15 to 49 years make their own decisions
regarding sexual and reproductive health andrights (UNFPA, 2024a). The existence of
this indicator highlights growing recognition
that restrictions on women’s autonomy yield
consequences for all of society (Menendez
and others, 2023; UN Women, 2018). Yet
more remains to be done, with experts callingfor further measures to understand women’s
experience of reproductive agency more broadly.

transformations in population data systems– not least of which has been the digitizationof the world’s information. Data systems for
censuses, surveys and civil registration and vitalstatistics, as well as routine health sector data,
have accelerated the speed of data processing,broadened the types of data available andoffered cost-cutting opportunities. Geospatial
information and satellite imagery have brought
invaluable possibilities for more granulartargeting. Even so, underdevelopment andinsufficient financing mean that many national
data systems remain deficient (UNFPA, 2024c).
Furthermore, while new data systems are on thehorizon, and innovation within existing systems
continues, protections must be put in place toguard against the risks to human rights foundin the world’s new digital and technologicalfrontiers (UNFPA, 2024b).
Thirty years after its genesis, the ICPD
Programme of Action endures as a compellingroad map to a better world. The path to progressis neither predictable nor linear, and despite
the crises and setbacks of the intervening
decades, there is reason to hope. We can createa world where every pregnancy is wanted, every
childbirth is safe and every young person’s
potential is fulfilled. We can. We must. And
together, we will.

Still, there has been tremendous progress overthe past 30 years. The ICPD Programme of
Action called for governments and institutions
to “strengthen national data systems” (UNFPA,
1994), which are essential for producing thehigh-quality, disaggregated data required to
identify and locate vulnerable groups, intervene
to support their development, and track progress
across relevant indicators each and every
year. Since 1994, there have been remarkable

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I N FOCUS

Who matters enough to measure?
The case of adolescent mothers
There is an often unspoken
assumption in policymaking anddata collection that the things whichmatter are measured, and that those
who are measured matter. As thisreport shows, that assumption does
not bear out.
One powerful example can befound in the data collection aroundadolescent fertility (i.e., the fertilityof girls and young women aged 10 to
14 and 15 to 19 years). Adolescentchildbearing is widespread, with anestimated half a million births togirls between the ages of 10 and
14 years, and 12.8 million births toadolescents aged between 15 and19 years taking place every year
(UN DESA, 2022b). Early motherhood,particularly for the youngest
adolescents, is “a form of genderbased violence. It is violence to force
somebody to go through pregnancy
or do something with her body thatshe doesn’t want to do”, says Carmen
Barroso, co-chair of the Independent
Accountability Panel appointed by the
UN Secretary-General. Complications
from pregnancy and childbirth
are the leading cause of death82

among adolescent girls and affectsocial and economic outcomes for
women, girls and their families. Yet
in many countries, the policies andprogrammes needed to reduce earlychildbearing are based on incomplete
data, which often lack disaggregation
by single age and other importantcharacteristics.
The good news is that more data
have become available to provide
insight into the scope and complexityof adolescent childbearing globally.
This is particularly true following
the 2030 Agenda for Sustainable
Development, which called forreporting on adolescent birthrates as an indicator of progress
towards achieving universal sexualand reproductive health care. Still,
the basic criterion for reportingon this indicator, SDG 3.7.2, andalso for estimating fertility rates
and age-speciﬁc fertility in the
United Nations World Population
Prospects (UN DESA, 2022b), is
the availability and quality of datafrom different sources – and there
remain consequential gaps in
our knowledge.

Unequal data quality
across countries
Figure 5 shows an assessmentof the availability of data onadolescent fertility worldwide
since 2015, representing a wide
range of sources of variable
completeness and reliability.
This assessment ﬁnds the mostconcerning lack of data – only
sporadically available data ornone at all – in 67 countries,
home to 20 per cent of all girls
aged 15 to 19 years. All 67
countries are in sub-SaharanAfrica, Asia, the Caribbean andOceania.
By contrast, the best available
data are in Europe and North
America and selected countries
from other regions, representing
78 countries accounting for
16 per cent of girls and young
women worldwide.
In very broad terms, the poorest
data quality and availability
are seen in regions where theinformation available suggests
higher adolescent fertility rates,

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3/28/24 11:17 AMwhich in some countries isconnected to high child marriage
rates (Molitoris, 2023). By
contrast, the best data quality
and availability are, generally
speaking, in countries with very
low incidences of child marriage
and adolescent pregnancy.

Unequal data quality
within countries
Disparities in data quality exist
not just across countries but
within them as well. In Brazil– a country in a category (seeFigure 6) considered to have thebest estimates of births by ageof mother – birth registration has
consistently improved, increasingfrom about 80 per cent in the
1990s to over 96 per cent in recent
decades (UNICEF, 2023; Hunterand Sugiyama, 2018). However,the lowest-income group registers
around 88 per cent of its births,

FIGURE 5

Births per 1,000 girls aged 15 to 19 years, data available from 2015 onward     § 

Births per 1,000 girls aged ¡ 15–19 §  
    

 «  
      «    
           ¢ ¥¡£         ¥¡         ¦   ¬  ¥¡   
    ®     S TAT E O F W O R L D P O P U L AT I O N 2024

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while the highest-income groupsurpasses 98 per cent.
Figure 6 shows how, despite thechallenges, continuous improvement
has been seen in the quality ofadolescent birth rate estimates.

other sources of data, such as
nationally representative surveys.
Figure 7 shows signiﬁcantvariation in adolescent birthestimates from 2000 to 2014. Still,there is notable alignment taking
place over time.

about ethnicity or race is rarely
available. These types of data
are not routinely collected atbirth registration and therefore
must be complemented bysample surveys among selectedsubpopulations.

In Bangladesh – a country withincomplete vital registration data
– only 56 per cent of births wereregistered in 2019 (UNICEF, 2023)
and estimates of adolescent birthrates need to be derived fromBetter data, disaggregated data,
still needed
Even in countries that fall into
the category considered to havecomplete civil registration andvital statistics data, information

One such example is Slovakia, where
no information on the ethnicity ofthe mother is collected when a childis registered. Data from surveys
among the Roma population foundthat its teenage fertility rate has

FIGURE 6

Comparison of birth rates among girls aged 15 to 19 years from different sources for Brazil,
2000–2021





 
















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   ¢£       ¯°       
  ¦   
   

84

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been consistently higher than thatof the Slovak population as a whole.
Comparing available survey data
since 1996 with civil registrationand vital statistics data on theentire Slovak population shows thatadolescent fertility was, on average,
more than seven times higher among
the Roma than among the entire
Slovak population. The most recent
rates, from 2016 to 2018, show only
slightly narrowed disparities, withadolescent birth rates for Romagirls still more than six times higher

than for all Slovak adolescents(Nestorová Dická, 2021).
Overall, these ﬁndings show thatthe empirical knowledge base onadolescent fertility has improved
greatly over the past decade.
But they have also made clearthat many countries and regions
continue to lack the coherent andtimely high-quality data necessary
for the development of policies
and programmes in support ofadolescent girls, young mothers, theirchildren and families. The ﬁndings
also highlight the importance ofcollecting additional information –beyond the standard socioeconomic
dimensions – relevant to eachnational context. Only then canmeaningful and efﬁcient solutions be
designed to protect the health andrights of every girl.
This text was contributed by the
Population Division of the United
Nations Department of Economic
and Social Affairs.

FIGURE 7

Comparison of birth rates among girls aged 15 to 19 years from different sources for
Bangladesh, 2000–2021







   
















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        ¯   ¢£     ¢ £¦  ¢¦ £        
¢±  £     ¢¡¥£    ¬

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STATE OF WORLD POP ULA TION 2024

CHAPTER 4


 

A Chadian proverb holds that a woman is thethread that weaves and strengthens family ties
in her household. By building peaceful families,
women can in turn build peaceful societies.

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In an ideal world, the advancement of women’s
reproductive rights and the promotion ofequitable access to sexual and reproductive
health and rights would be inherently motivatedby the principles of human rights and social
justice. But real-world sociopolitical contexts
often demand quantifiable arguments on
the short-term and long-term returns on
investments in such programmes. Indeed, thiswas understood to be the case in 1994. Though
the ICPD Programme of Action represented
a monumental pivot away from population
control policies and towards prioritizing therights of all individuals, the economic rationale
nevertheless remained critical for justifying
investments in these rights.
In fact, the economic and social gains associatedwith sexual and reproductive health andreproductive rights were listed as the firstobjective of the ICPD Programme of Action:“Among these objectives and goals are: sustained
economic growth in the context of sustainable
development; education, especially for girls;
gender equity and equality; infant, child andmaternal mortality reduction; and the provisionof universal access to reproductive healthservices, including family planning and sexual
health” (UNFPA, 1994).

This affirmation – that sexual and reproductive
health and rights are necessary enablers for thelarge-scale emancipation of women and girls as
empowered economic actors – has been borneout again and again in both the research and theaccounting that has taken place in the past 30
years. Significant social and economic gains areunlocked at the individual, societal and national
levels when sexual and reproductive healthprogrammes receive investment.
But there is even more of a case still to be
made. Certainly, the costs associated with
unintended pregnancy, maternal death anddisability (UNFPA, 2022a), sexually transmitted
infections (Owusu-Edusei and others, 2013)and gender inequality have been well studied(Wodon and de la Briere, 2018). What has beenless well understood is the scale of economic
returns that programmes advancing sexual andreproductive health and rights can yield. There
have been many challenges to studying these
returns on investment. For one, comprehensive
sexual and reproductive health and rights refers
to, and encompasses, a wide range of issues(Starrs and others, 2018): contraceptive services;
access to safe abortion where legal; access topost-abortion care; maternal and newborn care;prevention and treatment of HIV and other

The economic and social gains associated with sexualand reproductive health and rights were listed as
the first objective of the ICPD Programme of Action.

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sexually transmitted infections; comprehensive
sexuality education; prevention, counselling andtreatment for gender-based violence; prevention,
detection and management of reproductive
cancers; information, counselling and services
for subfertility and infertility; information,
counselling and services for sexual health andwell-being; and more.
An additional challenge to measuring returnon investment is that investments in one area
can result in cost savings in other programmes;
investments in contraceptive care can reduce
the need for abortion care and maternal healthservices, for example (Sully and others, 2020).
An exceptionally large body of research would
be necessary to fully understand returns on
investments across all the components of sexualand reproductive health and rights. The situation
is further complicated by the possibility that thecause-and-effect relationship between factors canwork in both directions. For example, utilizationof sexual and reproductive health and rights
programmes can lead to economic empowermentof women, but empowerment can also lead toutilization of sexual and reproductive health andrights programmes.
Yet another challenge is measuring how muchinvestment is being made in the first place.
Investments across a variety of interventions canbe seen as supporting sexual and reproductive
health and rights, but there is no comprehensive
accounting of the expenditures on theseinterventions. A look at official development
assistance and private sector donations over thelast three decades can offer some insights into
investment trends. Reporting by the United
Nations finds that, between 1990 and 1999,
official and private contributions to population

The design of this bilum bag from Papua New Guinea isinspired by the shape of a woman's ovaries and fallopian tubes.
© Papua New Guinea

issues stayed below $2 billion per year, butthat contributions markedly increased withthe start of the Millennium Development
Goals. Annual aid increased steadily from 2000
until 2011, when it reached $12.3 billion.
Since 2011, contributions have vacillated
between $9 billion and $13 billion per year,
and aid spent on population issues declined
as a percentage of overall global assistance.
Notably, the great majority of this spending hasgone to sexual and reproductive health, while
population data collection and policy analysis
has comprised a diminishing share of these
expenditures (UN ECOSOC, 2024). Even so,these figures represent a limited view into overall
global investments in sexual and reproductive
health and other areas, since they exclude
domestic spending.

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Still, there has been progress in calculatingsome returns on investment. In particular,
there have been efforts to look at the costs andgains associated with investments in specificcomponents of sexual and reproductive healthand rights. In 2022, UNFPA, together with
Avenir Health, Johns Hopkins University andothers, released estimates of the returns frominvesting in ending unmet need for familyplanning and ending preventable maternal
deaths (UNFPA, 2022). These UNFPA estimatesfound that spending an additional $79 billion
to scale up coverage of 29 essential familyplanning and maternal health interventions by
2030 would yield $660 billion in economic
benefits between 2022 and 2050. The spending
was estimated to avert 400 million unplanned
pregnancies, 1 million maternal deaths, 6 million
stillbirths and 4 million newborn deaths, withoverall economic benefits in the form of yearsof life gained, workforce participation, labour
productivity and more (UNFPA, 2022).
The Guttmacher Institute similarly quantified
the impacts of investing in sexual andreproductive health services, with a focus on
more than 100 core interventions covering
contraceptive services, maternal and newborncare, abortion services and treatment for the
major curable sexually transmitted infections inlow- and middle-income countries (Sully andothers, 2020).These estimates take into accountthe fact that investments in some services canyield crossover benefits to other health outcomes.
According to these estimates, providing thiscare would cost $68.8 billion annually, or$31.2 billion over current investments – an90

increase of only $4.80 per capita per year overcurrent expenditures. In return, they projected
unintended pregnancies would drop by
68 per cent, unsafe abortions would drop by
72 per cent and maternal deaths would drop by
62 per cent. In addition, newborn deaths would
drop by 69 per cent, and new HIV infections
among babies six weeks and younger would dropby 88 per cent.
The Guttmacher Institute also singled out theexpenditures needed to satisfy all of the unmet
need for modern contraception, and the costs
would be modest: To get from current levels ofcontraceptive use to levels that would satisfy allof the unmet need for modern contraception
in low- and middle-income countries, thecost would increase from $1.10 to $1.94 percapita. The short-term benefits of investments
in contraceptive care would more than coverthose costs: Every additional $1 spent on
contraceptive services would reduce the costof pregnancy-related and newborn care by$3. Each dollar above the current level spenton contraceptive services for adolescents, inparticular, alongside recommended investments
in pregnancy-related and newborn care, isestimated to reduce the cost of pregnancyrelated and newborn care by $3.70.
While these, and other, methodologies havediffered significantly – varying in their models,scope of estimation, timelines and baseline
assumptions – the findings have consistently
agreed that enormous value for money can berealized with increased investments in sexualand reproductive health.

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People left behindby the estimates
The estimates clearly demonstrate thatinvestments are most needed in the countries
and regions that have been left behind byadvancements in economic growth anddevelopment. Unmet need, for instance, ishighest in low-income countries, where nearly
half (46 per cent) of women who want toavoid a pregnancy are not using a modern
method. Sub-Saharan Africa and southern Asia
account for more than three quarters of thetotal increase in investment needed to provide
the full package of reproductive health services,
including contraception but also maternal healthand disease prevention services, for all in need,according to the Guttmacher Institute. Many of
the countries with the highest levels of unmet
need are also among those with the largest
proportion of women reporting they are unable
to make their own choices about contraception,
and among those with the highest fertility rates(Sully and others, 2020).
Unsurprisingly, but no less tragically, returnon-investment estimates are unable to factor in
the costs and returns of reaching those most left
behind within countries and communities. The
factors that marginalize people and communities
are so numerous and overlapping, and thebarriers so towering, that sexual and reproductive
health programmes must often be tailored andtargeted. One systematic review of adolescentpregnancy found that, among other factors,“belonging to an ethnic and religious minority
group also increased the risk” of becoming
pregnant in adolescence, noting: “it is unlikelythat strategies to reduce pregnancy among

women aged less than 20 years will be effective”
unless context-specific risks are addressed directly(Pradhan and others, 2015). In the best cases,
messages and interventions could, or evenshould, be co-created with these communities toensure accessibility and acceptability.
Such efforts could entail additional costs, or
could represent lower-cost interventions – thedata simply are not available to know. Yet there
is often resistance to investing the resources
needed to reach those who are furthest behind.
This resistance can be attributed to the sparsityof actionable data, but bias, negligence anddiscrimination likely also play a role.
All of this helps to explain why evidence suggests
the bulk of the gains seen over the past 30 years
have primarily reached those who are, andwere, well within reach of large-scale sexual andreproductive health programmes. As the inverse
equity hypothesis holds (page 65), progressoften comes at the cost of widening inequities
for the most marginalized, at least initially. But
continuing to reach only the “low-hanging fruit”
is likely to further exacerbate these inequities
and leave the ultimate goals of the ICPD
agenda unfulfilled. Furthermore, while initialcosts might be high, the tremendous levels ofneed among these left-behind individuals andcommunities could even mean that effective
investments yield significantly greater returns
than might be realized by programmes thattarget “low-hanging fruit”.
The analysis in this chapter looks at the longterm social and, especially, economic benefits ofinvesting in sexual and reproductive health andrights and women’s reproductive agency. Because
the returns on investment across the components

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FEATURE

Syphilis highlights threat to healthand human rights: stigma
Syphilis and other sexuallytransmitted infections are “secretdiseases,” says Dr. Adel Botros,
a specialist of dermatology andvenereology in Egypt, recalling aphone call he received more than 10
years ago. A hospital reached out toreport a case of congenital syphilis
in a newborn. Dr. Botros rushed tothe hospital and asked the father for
permission to see the patient – nofee would be charged. Rather thanagree, the father left the room; Dr.
Botros never saw him again.
Stigma around sexually transmitted
infections has long been used todivide communities and reinforce
hierarchies – even as it drives
people away from health services,perpetuating illness. Syphilis isperhaps the most notorious exampleof this, having been variously
described as “the French disease”,“the Neapolitan disease”, “the Polishdisease”, “the German disease”, “theSpanish disease” and “the Christiandisease”, among many other names,
typically by communities seeking toblame outsiders or enemies for theillness (Tampa and others, 2014).

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Today, syphilis – a bacterial
infection health ofﬁcials long
hoped would be eliminated by
antibiotics – is on the rise aroundthe world. Cases increased from
8.8 million in 1990 to 14 million
in 2019, and incidence rose from
160 to 178 per 100,000 people
over the same period (Tao andothers, 2023).
Yet available data indicate that
North Africa and the Middle East
have bucked this trend. While rates
of babies born with congenitalsyphilis have more than tripled
in the United States since 2016,
for instance, congenital syphilis
incidence in Morocco has plunged(WHO, n.d.b). In 2022, the World
Health Organization announced that
Oman had eliminated mother-tochild transmission of the disease(WHO, 2022).
These data defy age-old stereotypes
about syphilis in the Arab States
region, a history that holds importantlessons about disease, genderand power for the modern world,says Ellen Amster, a public healthprofessor at McMaster University
in Canada.
“Syphilis was really important ineugenics,” she explains. “Syphilis
was considered one of thesedegenerate things that would
destroy a population.” Westerncolonial authorities described Arabs
as inherently vulnerable to it. They
even invented a new term – “thedegenerate and diseased ‘syphilitic
Arab’” – to demonize and diminish
Muslims and Arabs, Prof. Amster’s
research has shown (Amster, 2016).
“Syphilis was tied to gender
disempowerment, to shame aroundsexuality – which always becomes agendered shame,” she tells UNFPA.
“What the French did to protect their
troops from these ‘syphilitic’ native
women – in Morocco and throughout
the empire – was to create closed
brothels that were basically a prison
for young women.”Those efforts were driven by“claims throughout the [Moroccan]
protectorate period that syphilis
prevalence was like 80 per cent,

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100 per cent,” Prof. Amster notes,
the result of false positive tests
and misdiagnoses of tuberculosis,
malaria and other diseases. “Theyfound that when they actually tested
women systematically, that syphilis
prevalence was 0.5 per cent or lessthan one half of 1 per cent.”
Modern society has yet to shake off
the shame – and power dynamics– attached to contagious disease.
In 2022, as global health authorities
worked to contain the spread ofMpox (also known as monkeypox),
they tried, simultaneously, tocontain the stigma swirling around
it. Reporting on Mpox “has usedlanguage and imagery, particularly
portrayals of LGBTI and African
people, that reinforce homophobic
and racist stereotypes andexacerbate stigma”, UNAIDS warned(UNAIDS, 2022). And illnesses
need not be sexually transmitted to
provoke intolerance; the COVID-19
pandemic saw waves of anti-Asian
xenophobia unleashed around theworld (HRW, 2020).
In designing programmes to addresscontagious disease, issues of power
and prejudice must be closely
considered. Despite the lessonsof history, this remains true forsyphilis as well, which is found to
disproportionately affect men who
have sex with men (WHO, n.d.c.).
Communities affected by illness
must be engaged, not stigmatized,
experts say.

Bousibir was a walled-off brothel in Casablanca, created by colonial authorities as an
STI-prevention measure. Historical photograph in public domain.

Even in the Arab States region,
where comparatively low rates ofsyphilis are seen today, vigilance isrequired, both against the disease
and against discrimination. In fact,says Dr. Botros in Egypt, the true
incidence of sexually transmitted
infections like syphilis cannot beknown because fear and shame —once weaponized so effectively
against the Arab world — persist
even now.

“Sometimes we discover a case bycoincidence,” Dr. Botros says. “Somepatients also don’t come in unlessthey have no other way to get rid of
the problem.”

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of sexual and reproductive health and rights are
too vast to summarize, this chapter focuses on
three essential elements: reproductive autonomy(represented here by contraceptive use among
women who wish to avoid pregnancy, with the
caveat that additional measurements are needed),
preventing gender-based violence and providing
comprehensive sexuality education. Each of theseelements is known to increase people’s ability
to realize many other dimensions of sexual andreproductive health and rights. Finally, thischapter examines the returns on investments thatare produced through the promotion of genderequality, which is a similarly critical enablerof many rights and choices. But in reflecting
on the possible returns on investment that canbe produced for each of these components,
it is important to note that these investment
estimates are blunt instruments looking at broad
impacts over large populations. Effectively
targeted programmes are likely to have different
costs, and potentially much larger impacts inthe form of human capital development, in
communities that have so far remained beyond
the reach of global progress.

The world is only
beginning to measure
reproductive agency.

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The long-term value of
reproductive autonomy
The world is only beginning to measure
reproductive agency, a concept that is criticallyimportant yet not yet well defined. The
Sustainable Development Goal indicators
on bodily autonomy (5.6.1) and enabling
environments (5.6.2) have been groundbreaking,exposing the vast numbers of people whose basic
rights are insufficiently realized. Yet only 115
countries or territories provide data on 5.6.2,
and only 69 provide data for 5.6.1, and these
indicators are only a starting point. Much more
information is needed to fully understand thestate of women’s reproductive agency.
Today, perhaps the best, though limited, measure
available to estimate investment returns on
reproductive autonomy is contraceptive use
among women who wish to avoid pregnancy.
This is because the scope and impact ofunintended pregnancy has been well researched.
About half of pregnancies in low- and middleincome countries – 112 million annually – areunintended (Bearak and others, 2020). The
majority, 77 per cent, are experienced by the 218
million women of reproductive age in low- andmiddle-income countries who want to avoid apregnancy but are not using a modern method ofcontraception (Sully and others, 2020).
There are significant inequities within andbetween countries in the level of unsatisfied
demand for contraception. Not only is unmet
need highest in low-income countries, butdisparities also exist by age group: Among
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proportion who have an unmet need for a modern
method is much higher among adolescent women
aged 15 to 19 years (43 per cent) than among
all women of reproductive age (24 per cent)in low- and middle-income countries (Sully
and others, 2020). Women from the wealthiest
households, living in urban areas and with higher
levels of education, also tend to experience lower
levels of unmet need than their counterparts. Asof 2015, about half of women in a union whowant to avoid pregnancy and who are living inhumanitarian crisis-affected countries are notusing any form of contraception, modern or
traditional – a rate much higher than the global
average (Loaiza and Liang, 2016) (see technicalnote on page 155).
The Family Planning Impact Consortium – acollaboration between the Guttmacher Institute,
African Institute for Development Policy, Harvard
University, Institute for Disease Modeling andAvenir Health – recently reviewed evidence
on the value of investing in family planning toenable women to reliably decide on the timing,
spacing and number of their children (Family
Planning Impact Consortium, 2023). The review
highlighted that having control over these coreelements of fertility allows women to attain ahigher level of education and affords them a wider
range of career choices than they would otherwise
have. Family planning also enables women toadvance further in their career paths. The benefits
in terms of educational opportunities also yield awide array of other benefits for girls and women:
For example, they are more likely to access healthcare, and to understand their rights and have theself-confidence to act on them.
Higher levels of female education are also
associated with women’s higher earnings (Grown

and others, 2005). Women with at least someprimary education earn 14 to 19 per cent morethan those with no education; women withsecondary education make almost twice as muchas women with no education; and women withtertiary education about three times as much as
those with no education, according to data fromup to 96 countries (Wodon and others, 2018).
Family planning also makes it possible forwomen who want to become mothers todetermine, at least to some extent, the spacing
between the births of their children and thetotal number of children they have – whichenables women to plan time away from work.
The costs of childbearing while in the workforce
include lost earnings due to a temporary exitfrom the workforce and a reduction in work
hours, which can both contribute to the atrophyof skills and act as disincentives for employers
to invest in skills building, ultimately leading
to compromised career trajectories (Adda andothers, 2017).
Women’s expectations regarding their ability
to control their childbearing can also influence
their choices at the beginning of theirproductive years. According to evidence from
Europe, a substantial portion of the career andincome costs of childbearing is determined by
the career paths that women pursue when they
are entering the workforce, based on expected
fertility patterns (Adda and others, 2017). In
Germany, it was estimated that occupational
choices at the beginning of the career represent
19 per cent of the lost wages associated withhaving children.
There is a reciprocal relationship between
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education can increase the knowledge andagency that women need to access and use
contraception (Blackstone and others, 2017).
In effect, contraceptive care unlocks a virtuous
cycle of empowerment and opportunity for
women. There are also multigenerational benefits
to satisfying the demand for contraceptive
services and thereby creating other opportunities
for women: Women who participate in theworkforce are more likely to expect the same for
their daughters (UNFPA, 2023). This paves theway to more life choices for children, including
the opportunity to delay marriage in order tocomplete their schooling and gain the long-term
benefits that education confers in the forms of
economic, social and personal empowerment.
It’s not just individuals who benefit from girls’
education. Employers are increasingly awarethat supporting sexual and reproductive healthand rights yields gains for their own bottomlines. Companies in Asia can use a returnon-investment tool developed by UNFPA toestimate the productivity benefits of supporting
employee reproductive health, for example(UNFPA Asia and the Pacific, n.d.).
Countries benefit as well, because reproductive
autonomy enhances women’s contributions to
the national economy. According to a modellingstudy in Kenya, Nigeria and Senegal, per capita
income would increase by 31 to 65 per centbetween 2005 and 2030 if all of the current
unmet need for modern contraception were
met in these countries (Bloom and others,2014). In Kenya, if two thirds of the unmet
need for modern contraception were met, thecountry would experience a 51 per cent percapita gross domestic product (GDP) increaseby 2050, through effects on the relative size of96

the working-age population (see technical noteon page 155). The relationship between women’sability to control their fertility and economic
gains to individuals, families and societies has
held up in several studies across a range ofsettings (Family Planning Impact Consortium,2023).
The Family Planning Impact Consortium review
also brings together evidence of the global
returns on investments in family planning.
For example, it has been estimated that a $1
investment in family planning would result ina $60 to $100 return, over time, in the formof economic growth (Kohler and Behrman,2018). The World Bank estimates that, globally,
the limited educational opportunities for girls
cost $15 trillion to $30 trillion in lost lifetime
productivity and earnings (Wodon and others,2018). It has also been estimated that, globally,female labour-force participation decreases by
10 to 15 percentage points, or close to two years,
with each additional child among women aged
25 to 39 years (Grepin and Klugman, 2013;
Bloom and others, 2009).
It should be noted that, while most studies ofthe longer-term economic benefits of helping
women control their fertility focus on satisfying
unmet demand for contraception, no methodof contraception is foolproof and, despite thepersistence of restriction on abortions in many
countries globally, some 6 in 10 unintended
pregnancies are estimated to end in abortion
every year (Bearak and others, 2020). Demand
for abortion – safe or unsafe – is therefore
unlikely to disappear.
Unsafe abortions are associated with a significant
percentage of maternal deaths and widespread

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illness and disability. It is estimated thatbetween 5 and 13 per cent of all maternal deaths
worldwide, as well as widespread illness anddisability, are attributed to unsafe abortions(Say and others, 2014). One estimated total costof abortion-related care in low- and middleincome countries is $2.8 billion annually, which
includes $1 billion for abortions (provided underboth safe and unsafe conditions) and $1.7 billion
for post-abortion care (Sully and others, 2020).
It has been estimated that, if all abortions in lowand middle-income countries that are currently
unsafe were provided safely, and if all needs forcontraceptive and abortion-related care weremet, the total cost of abortion-related care would
decrease to $600 million.

The long-term value of ending
gender-based violence
Securing the reproductive autonomy of all
people will be impossible without securing
freedom from gender-based violence, including
intimate partner violence. Worldwide, more than
one in four women aged 15 to 49 years who havebeen in a relationship report that they have been
subjected to gender-based violence in the formof physical or sexual violence by an intimate
partner in their lifetime, and 13 per cent havebeen subjected to physical or sexual intimate
partner violence at some point in the prior year
(WHO, 2021).
The prevalence of intimate partner violenceis exceptionally high in southern Asia andsub-Saharan Africa, where 19 to 20 per centof women are estimated to have experienced
intimate partner violence in the past 12
months. According to a review of evidence from46 countries, poorer and younger women andthose living in rural areas tend to be particularly
vulnerable to intimate partner violence (Coll andothers, 2020). Violence against women is also
typically higher among people who are forcibly
displaced and those living in conflict-affected
settings (Hadush and others, 2023; Horn andothers, 2021; Delkhosh and others, 2019). The
destabilizing effects of these conditions and theerosion of social networks and social protections
contribute to the greater risk of intimate partner
violence in these settings, where prevention andresponse efforts are also extremely challenging.
Disentangling the relationship between
violence and lack of reproductive autonomy
is challenging, not simply because sexual
violence and coercion directly undermine
bodily autonomy but also because reproductive
coercion is itself a form of violence. Still, there
are ways to understand some of the causal links,
for example through studies of intimate partner
violence and contraceptive use. Longitudinalstudies have demonstrated that women who
experience intimate partner violence are
significantly less likely to subsequently use
contraception, and they are especially unlikely
to rely on partner-dependent methods such as
condoms (Maxwell and others, 2015). Intimate
partner violence has also been linked withincreased incidence of unwanted pregnancies(WHO, 2013). Violence, then, is a driver ofthe individual and societal costs associated withloss of reproductive autonomy noted in thesection above.
But violence also levies a considerable
economic toll in the form of other adverse
reproductive health outcomes, including
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others, 2018; WHO, 2013) and inadequate
antenatal and skilled delivery care (Musa andothers, 2019). Costs can be intergenerational,
as women experiencing violence during
pregnancy are more likely to have miscarriages,
stillbirths and babies with low birth weight(Silverman and others, 2007; Boy and Salihu,
2004). Intimate partner violence and otherforms of gender-based violence can also resultin psychological trauma and stress, minor tosevere physical injuries, and death (WHO,2013). Women who experience non-partner
sexual violence are also at greater risk of alcoholand drug abuse and mental health disorders.
Health systems also bear significant direct costs
related to treating survivors of violence.
There are also workforce, productivity and wage
impacts. The erosion of women’s autonomy
brought on through gender-based violencecompromises women’s ability to make their own
decisions, pursue an education and contribute
fully in the labour force. Violence can result in
reduced employment opportunities due to fearof harassment or violence; limited occupational
choices, when women seek job options they
perceive as safer or more acceptable by an abuser;
lower productivity due to psychological distressand physical health consequences; and absences
to deal with the aftermath of gender-based
violence incidents (Vyas, 2013). A 2016 reportoffered a formula to help employers calculate theimpact of gender-based violence on operating
costs, including days lost, staff turnover andrecruitment costs (Walker and Duvvury, 2016).
What is the overall bill? Tallies differ, but every
finding is steep: The International Monetary
Fund estimated that every 1 percentage
point increase in the share of women subject

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to gender-based violence reduces economic
activity by up to 8 per cent in sub-SaharanAfrica – a decline attributed predominantly toa drop in female employment (Ouedraogo andStenzel, 2021). Research in 2022 estimateda global cost of intimate partner violence at
5 per cent of worldwide GDP and nearly
15 per cent of GDP in sub-Saharan Africa(Yount and others, 2022). One review of
evidence from 13 countries found the costs ofviolence against women to national economies
ranged from 0.35 to 6.6 per cent of GDP(Ibrahim and others, 2018). The elimination ofgender-based violence would not simply remove
these costs, it would result in immediate andlong-term benefits for individual productivity
and earning potential with impacts cascading
across generations.
Immediate economic gains can also be unlocked
when women are helped to escape violent
relationships. One small study of women in the
United States found that civil legal aid services
for survivors of intimate partner violence
resulted in an average of $5,500 net income
gains within one year of receiving assistance, a
return of $2.41 in personal income for every$1 spent on legal assistance (Teufel and others,2021). Women who received these services werealso less likely to be in poverty one year later.
Investing in the prevention of violence mightyield similarly strong returns.
And the benefits persist across populations andgenerations. Strong evidence shows genderbased violence prevention interventions
improve population health writ large (Ferrari
and others, 2022; Musa and others, 2019;
Bacchus and others, 2018). While some
programmes are more expensive than others,

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The economic case for inclusion
For reasons ranging from local circumstances to discriminatory norms, it can be more difﬁcult and costly toreach the most marginalized people. At the same time, “one-size-ﬁts-all” approaches can often be wastefulwhen applied to diverse groups; tailoring to women’s and girls’ language, religion, culture and contextual
factors, such as conﬂicts and level of infrastructure, can avoid waste and make better use of available
resources. Greater levels of need for sexual and reproductive health care to realize bodily autonomy andreduce marginalization can mean greater returns on investment and a stronger boost to development.
Tailoring can also limit longer-term costs from the social fragmentation that arises from worsening inequities
as services beneﬁt some people but stop at the barriers to reaching others.
Normalizing exclusion also comes with serious costs, which are impossible to fully account for because
exclusion renders people invisible. But one telling sign of these costs can be found in the economic gains
unlocked when exclusionary laws, policies and norms are eliminated. This case was made recently in areport on the decriminalization of same-sex activity, which found both micro- and macroeconomic gains(HIV Policy Lab and others, 2023). At the individual level, the removal of homophobic laws was foundto eliminate the labour and productivity costs of arrests, prosecutions and detentions, as well as theassociated physical and psychological trauma. At a larger level, at least one study holds that homophobia
costs the world $126 billion per year; improving the legal environment for LGBTQIA+ people, on the other
hand, was associated with a $2,000 increase in GDP per capita (Badgett and others, 2019).

a variety of them have been found to becost-effective, with effectiveness measured
as programme costs per disability-adjusted
life year averted through these interventions(Ferrari and others, 2022).
It is important to reflect on the importanceof tailoring to the specific contexts of thosein need.

populations, who experience gender-based
violence differently due to intersecting factors
such as ethnicity, gender identity, sexual
orientation, disability and economic status.
Adapting prevention efforts to address theroot causes of gender-based violence withinthese communities can increase the chances ofwidespread and lasting impact (Capasso andothers, 2022).

The tailoring of interventions is particularly
important for reaching marginalized

While tailoring is often assumed to be costly,
there are some indications that responding to

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the needs of people with multiple intersecting
vulnerabilities can increase effectiveness andtherefore value for money. For instance, somecommunity advocates caution that interventions
to reduce gender-based violence can result inthe mass allocation of resources to policing
and incarceration without addressing thestigmas and inequalities that lead to women’svulnerability to violence in the first place. It caneven result in the “unintended consequences ofcriminalization for women, which include not
only arrest but also intervention by the childwelfare system” (Goodmark, 2022), experts
note (a phenomenon also known as the “abuseto-prison pipeline” in which reporting violence
to a disbelieving authority, running away froman abuser or being trafficked can all eventuallylead to arrest). In these contexts, investments
in community services, survivor support andeducational interventions may produce morevalue for money.
It is also important to note that while studies
have identified risk factors that increase
vulnerability to intimate partner violence, alarge proportion of survivors do not experience
these risk factors, and that, in effect, “no safe
group of women was identified” (Coll andothers, 2021). Furthermore, men and boys
also experience gender-based violence at
rates believed to be seriously underreported(Wörman and others, 2021). So whileinterventions should be targeted to reduce
intimate partner violence, these tailoredapproaches will not be sufficient in themselves.
Population-wide laws, policies and social
norms must also be enacted to support genderequality, which in turn supports reductions
in violence and generates positive benefits for

100

community welfare, as well as the mental andphysical health of all people.

Long-term gains
from comprehensive
sexuality education
As is the case with ending gender-based violence,
access to comprehensive sexuality education
is a precondition to enabling reproductive
autonomy for all (Starrs and others, 2018) –and to unlocking all the attendant social andeconomic benefits.
Comprehensive sexuality education equips
people with the knowledge and skills they needto make informed, healthy and responsible
choices related to their sexual and reproductive
health throughout their lives. It covers a rangeof topics, including contraception, sexuallytransmitted infections, consent and healthy
communication in relationships – with benefits
spanning individual and public health, economic
empowerment and physical and psychologicalwell-being. Young people who are able to protect
themselves from disease, prevent unintended
pregnancies and prevent (or recognize andescape) violence are better able to pursue theireducation and participate and advance in theformal workforce.
While costs relative to impact have not been
fully assessed, it has been demonstrated thatcomprehensive sexuality education is associatedwith delays in the age of first sexual intercourse,
an increase in the utilization of contraceptive
methods (Kirby, 2008), and a reduction inadolescent pregnancy rates (Aguirre and Carrión-

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Yaguana, 2023; Kohler and others, 2008).
Programmes that link comprehensive sexuality
education with accessible, youth-friendly sexualand reproductive health services have beenshown to be particularly impactful in reducing
unintended pregnancy (Mbizvo and others,2023). The returns on investment associatedwith these results have been elaborated in the
reproductive autonomy section above (see “Thelong-term value of reproductive autonomy” onpage 94).
The integration of internationally agreed humanrights and gender equality standards into
comprehensive sexuality education programmes
has demonstrated short-term effectiveness inincreasing knowledge, improving attitudes, andincreasing communication with parents about
sex and relationships. It also has longer-term
positive impacts on outcomes such as partner
communication, sexual health knowledge
and awareness of services (UNESCO, 2016;
Constantine and others, 2015; Rohrbach andothers, 2015). Additionally, “gender-focusedprogrammes are substantially more effective than‘gender-blind’ programmes at achieving healthoutcomes such as reducing rates of unintended
pregnancy or [sexually transmitted infections],”
evidence reviews find (UNFPA, 2018a).

standards (UNFPA, 2018a), is age appropriate,
culturally relevant and context appropriate.
In fact, adapting comprehensive sexuality
curricula to local needs is an important elementof effective programming, as is ensuring
their acceptability to parents, families andlocal communities (including faith-basedorganizations). This point may be particularly
relevant when it comes to marginalized
communities. Education or curricula that do
not respond to community needs will likely failto mitigate harm and promote positive healthoutcomes. For example, some countries include
messages about the risks associated with “sugar
daddies”, or older men who offer to pay girls’
school fees or provide gifts in return for sexual
activity, due to the prevalence of this form of

The cultural and social aspects of comprehensive
sexuality education are just as critical as thehealth aspects, though these are sometimes
derided as unnecessary or ideological (United
Nations, 2023a). Yet comprehensive sexuality
education, when delivered to international

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The Suffragette Handkerchief is embroidered with
66 signatures, all of women imprisoned for their partin the Women’s Social and Political Union Suffragettedemonstrations of March 1912 in London. Image
courtesy of the Sussex Archaeological Society.

comprehensive sexuality education as one way
to help address and alleviate the rise in genderbased violence in the COVID-19 pandemic(Rollston and others, 2020), which speaks to
its broader potential as a means to influencenorms and behaviours.

exploitation. Others may include more emphasis
on normalizing menstruation due to prevailing
menstruation-related taboos (UNFPA, 2018a).
The evidence base on the impacts ofcomprehensive sexuality education beyond
health outcomes – for example on attitudes
and skills related to sexuality among
adolescents, the incidence of gender-based andintimate partner violence, and the prevalenceof gender-equitable norms and strong, healthy
relationships – is more limited (UNFPA,
2018a). Still, there is a growing consensus
that sexuality education programmes that
seek explicitly to empower girls and othermarginalized young people to see themselves
as equal members in their relationships are
particularly effective at equipping them toprotect their health and to engage as active
participants in society (Haberland andRogow, 2015). In fact, researchers proposed

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Unfortunately, the full impact of rightsbased comprehensive sexuality education has
yet to be realized, in part because educators
often minimize aspects of the curriculum
they are uncomfortable teaching (UNFPA,
2018a) and in part because the inclusion ofgender and social norms is often insufficient.
One review of national sexuality education
programmes in 13 countries in Africa, forexample, found that the weakest content
was related to gender and social norms(UNESCO, 2016).
Longitudinal studies of the longer-term
returns on investment are challenging
because of this inconsistency in programmeapplication, among other factors. But it
is also the case that returns on investment
greatly increase when comprehensive sexuality
education is delivered at scale and sustained
over time. Examples from a number ofcountries illustrate why: An analysis ofschool-based sexuality education programmesin six countries found programme costs
ranged from $7 to $33 per student reachedin countries with fully scaled-up programmes

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(Estonia, Nigeria and the Netherlands),
while those costs were $50 and $160
per student reached in countries where
programmes were still in the pilot stages(Kenya and Indonesia, respectively) (Kivela
and others, 2013). According to a separate
costing study in Indonesia, by the time an
in-school comprehensive sexuality education
programme has been running for three years,
the programme costs drop by 90 per cent(El Halabi and Annerstedt, 2021). Moreover,the biggest share of programme costs, teacher
salaries, is already embedded in educational
expenses; if these are excluded, the outlays forsexuality education programming are only
about 25 per cent of the full costs of scaledup programmes as estimated above (Kivela
and others, 2013).
Experts note that cost savings and investment
returns are likely even higher when theprovision of comprehensive sexuality
education is integrated into teacher-training
programmes, as this demystifies the topic
and enables effective delivery of the curricula
for a growing workforce of educators. The
investment also mitigates costs related to inservice teacher training (UNFPA, 2018a).
Finally, the costs and returns for providing
comprehensive sexuality education to out-ofschool learners are likely to be quite different
compared with in-school delivery. Out-ofschool learners are often the most vulnerable
to misinformation, coercion and exploitation,
but they are also often the hardest to reach.
Noting that some 263 million youth were outof school as of 2018, UNFPA and partners
have developed evidence-based guidancefor out-of-school comprehensive sexuality

education, offering recommendations for
curricula that are age appropriate as well as
tailored to the needs of specific groups ofpeople (UNFPA, 2020), such as young people
with disabilities; in humanitarian settings;
who are lesbian, gay, bisexual or gender nonbinary/nonconforming; living with HIV;using drugs; or selling sex.
Implementing programmes for out-ofschool learners carries numerous challenges,
including issues around the mobility ofyoung people as well as the lack of resources
available to tailor programmes to the needsof these varied groups (Australian Aid and
UNFPA, 2023; Fijian Ministry of Healthand Medical Services and others, 2023).
These programmes require not only monetaryinvestments but also the right people todesign and carry them out. Even though
the body of evidence on their impact islimited, comprehensive sexuality education
programmes for out-of-school youth holdpotential for substantial returns, considering
the size of this population and the heightened
vulnerabilities they face (Anderson and
Pörtner, 2014). These programmes also
have the potential to yield cost savings overtime, particularly when accounting forthe higher risks to sexual and reproductive
health (Anderson and Pörtner, 2014),
and health overall, associated with lower
educational attainment.
Further research on the impacts and potential
long-term cost savings of both in-school
and out-of-school comprehensive sexuality
education programmes, and on programmes
targeting marginalized communities,
is warranted.

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FEATURE

Local leadership reaches girls
most in needMaïmouna Déné is all too familiar
with beliefs and assumptions that
undermine equality for women andgirls in her community in Burkina
Faso. Literacy and labour-force
participation are lower for womenthan men, and gender-based
violence and harmful practices
are tragically commonplace. But
Ms. Déné, 43, has insight intoanother form of discrimination, onethat overlaps with gender: It is, as
she says, the “ignorance, social
burdens and myths” that affectpeople with albinism.
Around the world, people withalbinism face stigma, exclusion andviolence, and in the worst cases canbe subject to trafﬁcking, mutilationand murder. Many people withalbinism have vision challenges thatare not accommodated in schoolor work settings, leading to highrates of school discontinuation andpoverty. The impact on girls withalbinism is particularly striking:In Burkina Faso, one third of girls
with albinism do not ﬁnish primaryschool (Ero and others, 2021).

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The Sahel Women’s Empowerment
and Demographic Dividend Project(SWEDD) Project is bringing
hundreds of millions of dollars ofinvestment into gender equality
initiatives throughout West andCentral Africa. But to make the mostimpact, the programme is engaging
closely with local leaders like
Ms. Déné, who are able to identify
the speciﬁc needs of girls andwomen and how those unique needs
can best be addressed.
As the president of the Associationof Albino Women of Burkina Faso,
she became an ambassador for the“Stronger Together” campaign, a
SWEDD Project initiative performing
outreach in communities at a local
level. Through these efforts, she
has been able to secure social
inclusion for young girls andwomen with albinism, in schools
and through access to economic
opportunities and health care,including sexual and reproductive
health and information services. Her
association has signed agreementswith the health ministry, hospitals,

NGOs and other civil society
groups, and offers economic
training to support young people
with albinism and their families.
Since it was established in 2008,
some 450 women with albinism
and the parents of people withalbinism have beneﬁted from thistraining, including 280 who havelearned skills in soap making to gainﬁnancial independence and help
support their families.
Her role as a community leadermeans she is able to provide
support and guidance where it ismost needed. That work is intended
to help not only people livingwith albinism today but the next
generation as well: “Albinism beinga genetic phenomenon, I also ﬁght
for my children,” she says.
Syrah Sy Savané, in Côte d’Ivoire,is also acutely aware of the needs
within her community. But she isconcerned with a very different
group of vulnerable girls: those atrisk of abduction, forced marriage
and female genital mutilation.

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Ms. Savané, 50, has seen the ill
effects of these practices in her own
family: “I was raised by my paternal
grandmother in Diokoué, a village
in the north-west of Côte d’Ivoire.
All my aunts suffered early andforced marriage. I was entrusted
to them when they were married,
I kept them company and saw themvery unhappy. I also lost a cousin
after she was subjected to female
genital mutilation.”
Ms. Savané was fortunate to havean ally in the form of her father, whostrongly opposed female genital
mutilation. “My aunts wanted to haveit done to me too, but my father, who
was a teacher, always refused.”
Her experience drove her to becomea social worker, before assuming
a post in the ministry for women,
families and children where, as achild protection expert, she saw how
girls were being pulled from school
to be married off. The problem,
it became clear, was much larger
than reaching individual girls. “It
was necessary to target not thestudents, but the parents, who wereseeking marriage for their daughters,
as well as community leaders andreligious guides.”Maïmouna Déné is ensuring that girls with albinism in her community have the education,
skills and empowerment they need. Image courtesy of Maïmouna Déné.

Today she is applying these lessons
in her work with the SWEDD Project.
The project plans were written bytechnicians working in the very
communities they were trying toreach, she says. This has proved
essential in meeting the speciﬁc

needs of the girls and their families.
Safe spaces, husbands’ clubs andother interventions are making a realdifference and, Ms. Savané says,“shining a light where young girls
thought they had no rights”.

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Dividends of agender-equal world
All of these elements of sexual and reproductive
health – promoting individuals’ rights andability to decide whether and when to havechildren, ending gender-based violence andproviding comprehensive sexuality education
to international standards – are well rooted inhuman rights priorities, including the imperative
to achieve gender equality. Gender equality andsexual and reproductive health have a powerfulmutually reinforcing relationship. Progress on
both fronts – advancing gender equality andsexual and reproductive health and rights – intandem can be expected to maximize the socialand economic benefits for societies as a whole.
Perhaps the most powerful illustration of this is
the essential role of both sexual and reproductive
health and rights and gender equality in the
demographic dividend. When women use
contraception to avoid unplanned births, thesubsequent decline in fertility eventually leads
to a smaller proportion of dependent children
in the population relative to the size of theworking-age population. This demographic
shift can lead to what is commonly referred toas the demographic dividend: increased rates of
productivity and economic growth. The conceptof the demographic dividend was inspired byobservations of economic growth following
fertility decline in East Asian countries from the
1960s to the 1990s (Bloom and others, 2003).
But the demographic dividend does not
automatically follow a fertility decline. In Asia,
economic growth during the demographictransition was attributed, in part, to women’s

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participation in the workforce (Bloom andothers, 2009). Some evidence and policy
analyses have concluded that the demographic
dividend will not be replicated in the absenceof some measure of gender equality alongside
fertility declines (Marone, 2016). Indeed, fully
one third of the economic growth experienced
in Asia during the demographic dividend
years has been attributed to improvements inwomen’s empowerment and participation in thelabour force alongside rapid fertility transition(Cardona and others, 2020).
In recognition of this, the United Nations andthe World Bank Group launched the Sahel
Women’s Empowerment and Demographic
Dividend (SWEDD) Project, a regional
initiative to simultaneously reduce genderinequality and increase access to reproductive
health services, in order to yield the benefits ofa demographic dividend in the participating
countries – those with some of the globally
most left behind women and girls when
considering indicators such as maternalmortality ratio, child marriage prevalence andadolescent birth rate.
The SWEDD Project is structured aroundthree components: gender-transformativeinterventions that promote girls’ and women’ssocial and economic autonomy; programmes
to strengthen reproductive, maternal,
newborn, child and adolescent health andnutrition services, including by increasing thenumbers of qualified health workers at thecommunity level; and fostering regional andnational commitments to gender equality andproject implementation, as well as capacity
for policymaking. Since it began in 2015, theproject has reached nine countries (Benin,

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Reaching those most globally left behind
The SWEDD Project targets girls most left behindby global progress, seeking to reach districts andcommunities affected by some of the world’s
highest rates of female genital mutilation, childmarriage, unmet need for contraception, lower
education attainment levels and poverty, as well asfactors such as limited access to mass media or
telephone (Camber, 2020). One important elementof the SWEDD Project is life skills education (aculturally appropriate term for comprehensive
sexuality education) provided through safe spaces
located both in schools and within the community.
The locations and constituents of the safe spaces
are selected based on vulnerability criteria,
ensuring the most disadvantaged adolescents andyoung women, including those out of school, arereached. The curricula are intended to enhance
girls’ knowledge and skills, with a speciﬁc focus
on reproductive health, gender and human rights
as well as ﬁnancial capacity and economic
empowerment – an acknowledgement of the
deep connection between sexual and reproductive
health and rights and human capital development.
Importantly, the life skills curricula are developed
through a participatory process designed toconsider the sociocultural realities of each country,
and are delivered by community mentors, ensuring
the implementation is locally relevant.
The ability to tailor programming to local needs
has been instrumental in the success of thework of Senami Mariette Atolou, a mentor at asafe space in Benin. Ms. Atolou experienced
an adolescent pregnancy and subsequent
abandonment; now 46, she is able to shareinsights from her life with girls facing similar
challenges: “My relationship with young people,
girls, allows me to guide them,” she says.
As the SWEDD Project’s name suggests,
the investments are designed to unlock a
demographic dividend, meaning economic and108

development results on a generational scale.
The multifaceted initiative – which includes not
only life skills but also midwifery training, efforts
to end gender-based violence and improved
access to contraceptive care and economic
opportunities – is intended to create positive
ripple effects that contribute to the broadertransformation of societies in Sahelian countries.
Measuring return on investment – which stands
at around $850 million – will necessarily taketime, but baseline data for all countries havebeen collected, enabling consistent and thoroughmonitoring of results.
And early results are promising. As of December
2023, the programme component aimed at
empowering women and girls saw a 96 per centschool retention rate for adolescent girls insecondary schools receiving interventions,up from 75 per cent at baseline. In addition,
96 per cent of adolescent girls and women inlife skills training clubs demonstrated goodknowledge on the harms of child marriage andearly pregnancy and on the beneﬁts of birth
spacing, compared to 74 per cent at baseline;
and 21,087 cases of gender-based violence andharmful practice were referred to health, social,legal and security services, up from 5,415 atbaseline. New users of modern contraceptives
numbered around 903,000, up from 24,000
at baseline; and an estimated 8,790 maternal
deaths, 2,422,000 unintended pregnancies and
830,000 unsafe abortions were averted (UNFPA,
2024d; UNFPA, n.d.a.).
Other outcomes, such as wide-reachingawareness campaigns and the establishment of
a network of national observatories to monitor
the implementation of public policies to support
the demographic dividend, show promise that
more change is on the horizon.

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Burkina Faso, Cameroon, Chad, Côte d’Ivoire,
Guinea, Mali, Mauritania and Niger), and three
more (Gambia, Senegal and Togo) have been
approved for further expansion.
Key to this effort has been participationand partnership by civil society, women’sorganizations and other stakeholders in aholistic and integrated way. For example,
more than 20,000 community and religious
leaders have been engaged in promoting
girls’ education and adolescent sexual andreproductive health, and ending gender-based
violence during the course of the programme(UNFPA, 2024d). The participation ofcommunity and faith leaders offers both asign of local-level investment and also a strong
indication that the programme is positively
influencing social and gender norms at the
ground level. The coordinated participation of
stakeholders at all levels also enables the sharingof lessons across countries, opportunities for
productive South-South cooperation andpossibilities for the scaling-up of interventions.
Programmes like this can have powerful positive
impacts on countries, and even on the national
economy. It has been estimated that closing
the global gender gap and advancing women’sequality in the public, private and social sectors,
even in the absence of further investments
in sexual and reproductive health and rights
programmes, could double the contribution of
women to global GDP growth, and could add$12 trillion to global GDP in the course of
10 years (McKinsey Global Institute, 2015).
As the SWEDD Project’s early achievements
show, integrated action to empower womenand girls through mutually reinforcing
interventions can unleash a virtuous andsustainable cycle of human development –making the demographic dividend a reality for
those not yet reached by the arc of progress,
and lifting up the potential, rights and wellbeing of every girl. And these early results are
just the beginning – the full impact will only
be seen when the women and girls of today
complete their educations, embark on theircareers and plan the families of their choosing.
In all, the economic case for investing inprogrammes that advance reproductive
autonomy and other aspects of sexual andreproductive health is strong – and the returns
are even greater, perhaps synergisticallyincreased, when these happen alongside
improvements in gender equality. The
world can and should work towards further
strengthening the economic case for investingin programmes to serve the most marginalized,
the most pushed behind. More data andanalysis are needed to understand the full rangeof returns unlocked when we target investment
towards those who need it most. But even withthe evidence base we have now – coupled with
common sense and a sense of what is right –the case is clear. The next step must be action.

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STA TE OF WORLD POP ULA TION 2024

CHAPTER 5

Weaving a
  

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“If you have come here to help me, you arewasting your time. But if you have come because
your liberation is bound up with mine, then let
us work together.” These were the words of Lilla
Watson, an indigenous activist from Australia,
at the 1985 United Nations Decade for Women
Conference in Nairobi.
Today, perhaps more than ever, this notion
is gaining momentum. Advocates, justiceorganizations and leaders are embracing a visionin which strengthening the rights and welfare ofindividuals reinforces those of the collective, andvice versa (see timeline on pages 34–39). It is
increasingly clear that collective action offers the
only path forward when it comes to many of theworld’s largest concerns, from climate change toincreasing demographic diversity to the digital
revolution. Collective efforts that reinforce
individual rights are essential, too, when it comesto sexual and reproductive health. As this chapter
elaborates, humanity will be ill equipped toaddress the challenges ahead unless we embrace
an approach that is grounded in human rights aswell as scientific and historical fact.

“If you have come here tohelp me, you are wasting
your time. But if you
have come because yourliberation is bound up
with mine, then let us
work together.”— LILLA WATSON

112

Three decades of progress:a promising start
History shows us that solidarity works. The
power of collective action – by individuals,
advocates, civil society, institutions and Member
States – should not be in doubt, but it isnonetheless worth reflecting on the power andpromise of such efforts, which have shaped thepast 30 years.
Indeed, since the ICPD, women’s ability
to use modern contraceptives has increased
significantly: Between 1990 and 2022, thepercentage of women married or in a union
using modern contraceptive methods rosefrom 11.5 to 33.5 per cent. In middle-income
countries, this percentage increased from 52.9
to 61 per cent (UN DESA, 2022c). In the
period between 1990–1994 and 2015–2019,
there has been a 19 per cent decline in theunintended pregnancy rate (Bearak and others,2018), a major achievement in women’s ability
to exercise decision-making power over theirbodies and futures. Relatedly, the global maternalmortality ratio fell by more than one third
between 2000 and 2020 (WHO and others,2023). Advances in medicine and health systems
played a considerable role in both of thesemilestones. Contraceptive technology allows awide choice of safe, reliable methods. Skilled
health workers, available essential medicines andquality reproductive health services provided tointernational standards can also be credited forthese gains in maternal survival.
It is no coincidence that this progress followed
the watershed consensus reached at the ICPD in
Cairo. The underlying agreement of the ICPD –CHAPTER 5: Weaving a collective future

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that sexual and reproductive health and rights
are inextricable from broader sustainable
development and, therefore, the welfare of all
people – was carried forward in many of theinternational, regional and global initiatives
undertaken since 1994.
One important example is the Millennium
Development Goals (MDGs), globally agreed
goals promoted between 2000 and 2015,that saw significant improvements in humanhealth and well-being. The contributionof global solidarity and investment toachieving those results has been muchdebated, but recent research finds Africa
experienced “a significant increase inprogress for both maternal and underfive mortality reduction… Amongthe progress achieved during the
MDG campaign period, 81 and68 per cent were attributed
to the worldwide MDG
campaign for thematernal and under-five mortality reduction”(Cha, 2017). The researchers call for more
attention to be paid to these positive results,
noting “dominant pessimism about the subSaharan African countries, which showed thebest performance among all the regions, canovershadow their substantial achievement”.
A similar point must be made about the presentday. Last year, 2023, marked the midpointof global efforts to achieve the SDGs, whichbuild upon the MDGs. Progress in achieving
the SDGs has been greatly hampered by the
COVID-19 pandemic as well as the grievous

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41.3 in 2023 (UN DESA, 2023). These gains,
made even amid the extraordinary disruptionsof the pandemic, demonstrate that the SDGs
are achievable – if we follow the evidence
and reject the pessimism that all too easily
overshadows progress.

impacts of conflict, climate change, biodiversity
loss and pollution. Despite these challenges,
there have been signs of success, including on thetargets linked to the ICPD agenda. For instance,
the proportion of women in lower and single
chambers of national legislatures grew by 4.2
percentage points between 2015 and 2023. The
proportion of women whose need for modern
family planning was satisfied increased modestly,from 76.5 to 77.6 per cent, even as the global
population grew – and the proportionately
largest increase was seen in sub-Saharan Africa,
the area with the greatest need. The global
adolescent birth rate fell even more significantly,
from 47.2 births per 1,000 girls in 2015 to114

Undeniably, the pace of progress must be
accelerated. Success has stagnated on many
counts, most notably in the failure to improvematernal mortality rates between 2016 and2020 (WHO and others, 2023). Adolescentpregnancy rates remain high across thedeveloping world, with nearly one in three
young women aged 20 to 24 years having given
birth in adolescence (UNFPA, 2024a). Global
abortion rates have been steady for decades,with declines observed only in countries where
it is broadly legal (here, the abortion rate fell
from 46 per 1,000 women in 1990–1994 to 26
in 2015–2019) (Bearak and others, 2018). And
for the first time ever, the world has trend dataon women’s ability to exercise bodily autonomy(as measured by SDG 5.6.1) from 32 countries.
A forthcoming analysis of these data shows apositive trend in 19 countries and a negative
trend in 13 (UNFPA, n.d.).
It must also be acknowledged that reversals inprogress are taking place. Rates of gender-based
violence skyrocketed in many countries during
COVID-19 lockdowns, and new technologies
are enabling this abuse to be perpetrated in
virtual environments (University of Melbourneand UNFPA, 2023). And in some countries,
the very heart of the ICPD – the consensus on
reproductive health and gender equality – isbeing undermined, with backtracking often
directed at the most vulnerable. In one country,
migrants are denied health care (MTI-Hungary

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Today, 2019); in another, enactment of
restrictive abortion laws is expected to exacerbate
health inequities for people with chronic
health conditions, especially people from racial
minorities (Hassan and others, 2023). In yet
another, a military takeover means that women
have largely been confined to their homes anddenied education and employment (United
Nations, 2023b). Elsewhere, discriminatory laws
have been expanded to call for the death penalty
for LGBTQIA+ persons (United Nations,2023c).
But we cannot allow these obstacles to derail
our demonstrated trajectory of progress. As
this report notes, the world is at an inflection
point, a moment where the weight of evidence
points towards inclusive solutions even as thestorm clouds of uncertainty, polarization anddisinformation gather on the horizon.

A vision of the world to comeThe changes of the past 30 years represent
tectonic shifts in how the world works, in ourhealth systems, political institutions and social
norms, and in our expectations for our bodies,families and futures. These changes are only
going to accelerate in the coming decades. At
the end of 2023, UNFPA brought together aconsortium of experts in human rights, sexualand reproductive health, demography, genderbased violence, technology and climate change,
seeking to forecast the biggest challenges andopportunities for humanity looming just over thehorizon. Many of the projections are disquieting– warranting not pessimism but vigilance.

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The ongoing climate catastrophe is expected
to greatly exacerbate global inequalities.
Low‑income populations who havecontributed least to climate change are most
likely to suffer from climate-related cyclones,
droughts, flooding, heatwaves and otherconsequences. Additionally, climate change
is expected to trigger increased national andinternational migration, which – as this report
has highlighted – is a significant, and growing,cause of marginalization, with particularly
deleterious impacts on sexual and reproductive
health and rights. Crisis conditions andservice disruptions are likely to place greatest
stress on already marginalized groups, forexample leading to greater incidence ofgender-based violence and harmful practices
like child marriage. Potential threats to
reproductive health include greater difficulty
conceiving, greater risks of miscarriage andrisks to both maternal and newborn health(UNFPA, 2024e).
Demographic trends are also projected togreatly reshape the world as we know it,with many countries experiencing significant
population ageing and others experiencing aboom in young people – a divergence likely
to grow more extreme over time. Whilemigration trends are difficult to predict,disparities in population growth rates, as wellas uneven economic development and otherfactors, could potentially amplify the pace of
global migration and related concerns overthe health and rights of migrants. Anxiety
over demographic changes, including theperceived threat of population decline and very
low fertility in certain places, is leading somepolicymakers to push back against the valuesof the ICPD (UNFPA, 2024f ).

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The many successes that have been achieved in
the area of sexual and reproductive health andrights could well be put in jeopardy as the world
grapples with these and other megatrends. In
anticipation of these changes, countries must
reaffirm the basic principles of the ICPD toensure that the rights and services guaranteedby the Programme of Action are available toeveryone – including migrants and refugees.
Governments and societies can also address
the rising challenges by harnessing newtechnologies. Such advances can, for example,
go further towards ending the world’s unmet
need for contraception and address the growing
issue of infertility. Health systems also require
strengthening, and opportunities are emerging
in the form of digital health records andidentification, and increasing access to digital
health tools (UNFPA, 2024). Such digital
tools offer great potential but only if the digital
divide – the gap between those who benefit
from information technology and those who
do not – is eliminated or greatly reduced. The
downsides of the digital revolution, including therise in disinformation campaigns, must also be
addressed. Digital tools and information can beweaponized against vulnerable groups based on
ethnicity, sexuality or gender. And technologyfacilitated gender-based violence is taking asignificant toll on the health, safety, and politicaland economic well-being of women and girls –and society as a whole (UNFPA, 2024b).
Finally, as Chapter 3 of this report emphasizes,
advancing the ICPD Programme of Action andaddressing emergent challenges require datasystems that provide insight into demographic
and social realities while enabling policymakers
to anticipate the impact of megatrends. Since

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1994, global data systems have grown stronger,
but many national data ecosystems remain
under-resourced. Without reliable data, noneof the world’s challenges can be confronted
successfully. At the same time, we must face up
to the growing risks related to data privacy andmisuse that accompany rapid advancements indata technology. And, of course, data systems
must generate and analyse disaggregated dataso that existing inequalities can be addressed(UNFPA, 2024c). As this report has shown,
the will and capacity of governments to collectand analyse these data will be essential toaddressing the inequalities that hinder fullachievement of the ICPD and SDG agendas.
The range of possible global futures, both
positive and negative, is vast. Indeed, while
global challenges are growing, so too is theunpredictability of their possible outcomes.
In this time of uncertainty, one fact is inescapable:
Our fates are interwoven. Amid the mostintractable disputes and existential concerns,
the only way forward is through collaboration,solidarity, shared values, narrowed inequities
and the assurance of hope and dignity for all.

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FEATURE

Sexual health of older adults
emerging from the shadows
Some women arrived alone. Somecame with friends. Some were as
old as 70. All came for the Age ofLove “café” at a community centre in
Northampton, England, one Saturday
afternoon in August 2023.
Inside, organizers played upbeat
music while the women waited forthe day’s programme to begin. The
curtains were drawn for privacy.
Some women chatted with friends
while others sat silently.
“At ﬁrst, everyone was a little
nervous, given that for the next threehours, the conversations would be
about sex and health,” says Audrey
Tang, a psychologist, educatorand co-organizer of the event. “Butalmost immediately, people started
opening up – and having fun,”Ms. Tang adds.
The event was one of a series
in which older adults have an
opportunity to learn in a “convivial
and conﬁdential” environment about
sexual health and get answers toquestions about their bodies andsexuality as they age, according toUniversity of Shefﬁeld psychology
professor Sharron Hinchliff, who
created the Age of Love seriesin 2019.

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She says the events help ﬁll theinformation void often encounteredby older adults when they want
to ﬁnd out about matters such as
menopause, erectile dysfunction,or the impacts of illness andmedications on libidos.

United Kingdom’s older adults, Prof.
Hinchliff says. And that need is likely
to grow as people are living longer.
Life expectancy in the country is
about 80 years, and today about one
in four people is aged 60 or older(UN DESA, 2022a).

“We keep hearing from older
adults that there is no easy way
to ﬁnd trustworthy information,”
Prof. Hinchliff says. Part ofthe problem is that there’s anassumption that older adults aren’t
sexual and therefore don’t need
information, she explains.

Older adults tell Prof. Hinchliff theirsexual health needs and concerns
are often neglected or ignoredby doctors because of their age.
“This ranged from not being told
when it was safe to resume sexualintercourse after a hysterectomy
to being advised that painful sex
was ‘due to age’ but without being
offered any help or advice,” Prof.
Hinchliff says.

“But we know that many older adults
are sexually active,” she adds. Manyothers would like to be but are not:One study in the United Kingdom in2019 found that about one in four
men and one in six women between
the ages of 55 and 74 have a healthcondition or take a medication
affecting their sex lives (Erens andothers, 2019). According to the
Healthy Lifespan Institute at the
University of Shefﬁeld, the problem
is even worse for the one in two
people aged 65 or older living with
two or more chronic diseases.
“There is a large unmet need” for
information and services among theAnecdotal and scientiﬁc evidenceshow that the sexual rights ofolder adults are rarely met. In
response, Prof. Hinchliff, along with
University of Shefﬁeld research
associate Stephanie Ejegi-Memehand Age-Friendly Shefﬁeld learningofﬁcer Gilli Cliff, devised the United
Kingdom’s ﬁrst Sexual Rights
Charter for Older Adults, which aims
“to ensure that people are treatedwith dignity and respect, and without
discrimination, as they age when it
comes to their sexuality”.

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Denying the sexual rights of older
people can take many forms,
ranging from being prevented fromforming intimate relationships
in care homes to being excluded
from sexual health and education
campaigns, including ones aimed atprevention and treatment of sexuallytransmitted infections.
In 2019, Age UK showed thatbetween 2014 and 2018 new
diagnoses of sexually transmitted
infections fell by more than 7 percent among men aged 20 to 24,
yet they rose by nearly 14 per centamong men aged 45 to 64, and by
23 per cent among men and women
aged 65 or older during that same
period (Age UK, 2019). The trend
reﬂects age-related inequalities
in sexual health services andinformation in the United Kingdom,
Prof. Hinchliff says.
Meanwhile, older adults are lesslikely than younger people to reportsexual assault because of concerns
about not being believed because
they do not ﬁt the “image of therape victim”, she says. And they
may delay or avoid seeking help forsexual matters because they are
painfully aware of the prevailing viewthat older people should not or do
not have sex.
All these challenges arecompounded for older adults who
are gay, lesbian or transgender, arefrom racial or ethnic minorities,
come from more conservative
backgrounds or are from poorer
households, Prof. Hinchliff says.

At the Age of Love café in Northampton, England, older adults can learn about sexual
health in a safe and conﬁdential environment. © Sharron Hinchliff

The Sexual Rights Charter is meant
to help health-care providers,social workers, community groups,
the volunteer workforce andpolicymakers better understand andrespond to the needs of older adults.
It is meant to “underpin” every
initiative aimed at making Shefﬁeld agreat place for people to grow old.
“The idea for the Charter was bornout of frustration” because many
issues can be easily addressed byasking patients simple questions
about, for example, how a
medication might be affecting their
sex lives, Prof. Hinchliff explains.
The ideas within the charter are
now being translated into action:
With colleagues at the Universityof Shefﬁeld, Prof. Hinchliff created
AgeSexandYou.com, a website withstraightforward information about

sexual health and sexuality for older
women and men.
In 2018, the World HealthOrganization welcomed AgeFriendly Shefﬁeld, a partnership oforganizations and individuals, into
the global Age-friendly Cities andCommunities network. As part ofthis network, Age-Friendly Shefﬁeld
is striving to create age-friendly
physical and social environments.
The café events are part of thiseffort. The ﬁrst events were aimed at
women, but one in December 2023,“Breaking the Silence,” targeted men
and focused on their mental healthand well-being, including sexualwell-being. “Men want to talk about
these things as well,” Prof. Hinchliffsays, “but we often don’t give themthe chance or the right environment
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The journey ahead
As this report acknowledges, there is no onesize-fits-all solution. But there are approaches,rooted in both ample evidence and international
agreement, that can and will advance ourshared goals. They include intensifying ouralready agreed-upon efforts to meet the needsof those most left behind, ensure inclusivity
in decision-making and leadership, advanceboth comprehensiveness and universality inhealth care and increase access to quality,
unbiased, medically accurate reproductive healthknowledge for all.

Tailoring
The needs and perspectives of people whoare subjected to the forces of marginalizationmust be proactively incorporated into sexualand reproductive health care and efforts tosecure their reproductive rights. As WHO
acknowledged in 2009, “although poverty
and gender signficantly influence health andsocioeconomic development, health professionals
are not always adequately prepared to address
such issues in their work” (WHO, 2009).
The research summarized throughout thisreport highlights how poverty and gender
are just two of many factors that overlap tocontribute to many people’s lack of access toand use of reproductive health care services
and the realization of their reproductive rights.
Addressing those gaps means looking at issues ofinclusion, tailoring and targeting.
One concern is that tailoring to specific groups
seems, on a superficial level, to contradict
efforts to implement integrated models ofcare, wherein sexual and reproductive healthinformation and care are provided through120

existing service delivery points. For example,
integrating sexual and reproductive healthservices within HIV services has been shown
to improve access, quality of care and healthworker productivity, while also reducing stigma(Ford and others, 2021). But tailoring andintegration need not be antonyms, and in fact
they can be complementary. Complex caremanagement programmes, for example, havebeen recommended to use the data and toolsof existing health systems (including medical
records analysis and patient classification
systems) while also emphasizing the individual
circumstances that impact service uptake andeffectiveness, factors like precarious housing,transportation and social conditions (Williams
and Fendrick, 2022). Tailored approaches, then,need not supplant integrated health systems.
Tailoring and targeted approaches can takemany forms, but key to the effort is themeaningful participation of members of theaffected community. These communities can,for example, identify approaches that are as
simple as translation services or targeted outreachefforts, or they may call for more complex and
expensive efforts, including specially designed
or implemented stand-alone programmes.
These latter programmes can provoke particular
resistance, with some critics arguing that they
actually reinforce stigma and exclusion bytreating certain populations as the “other”.
Evidence, however, shows that the opposite
can be true, with tailored programme designs
actually granting people a space that ensuresdignity and safety and reflects their specificneeds, which may be different from others.
Perhaps the most salient example of this is thecase of HIV, which disproportionately affects

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stigmatized communities, including sex workers,
gay men and other men who have sex withmen, transgender people, people who injectdrugs and people in prisons and other enclosed
settings. In 2021, these populations and theirsexual partners accounted for 70 per cent of new
HIV infections, and each of these populations
experienced inequitable access to safe, effective
and quality HIV services. Furthermore, theresulting association between these groups andHIV transmission contributes to a cascade offurther rights abuses, including discrimination,
violence and criminalization (USAID, 2022).
One study of successful HIV prevention andtreatment programmes in Asia highlighted
the importance of meaningfully engaging
with key populations in services, researchand programming, citing as an example thetransgender-designed and -led “Tangerine”
community health centre in Thailand (Yangand others, 2020). The availability of such
community-led services has been shown toresult in a much greater usage of HIV diagnostic
and treatment programmes among targetedgroups (Nugroh and others, 2017). A metaanalysis of HIV programmes for female sex
workers in Africa, for instance, found that thekey to reducing the transmission of HIV wasconsulting with the communities and targeting
their specific needs in HIV prevention (Atuhaire
and others, 2021).
Community inclusion, participation of the mostleft behind, bringing everyone to the table –these are lofty goals, but the obstacles are realand plentiful. One major barrier is the questionof financial resources – a refrain that is likely
to become even more frequent in constrained
funding environments. But costs may not be
the biggest barrier – indeed, Chapter 4 of thisreport highlights the extraordinary economic
potential that can be unlocked when the sexualand reproductive health and rights of all people
are realized. Instead, the attitudes, assumptions
and divides that contribute to marginalization
may actually be greater challenges to progress.
From hostility towards LGBTQIA+ people, topoor (or even non-existent) communication withethnic minorities, to neglect in implementing
even simple measures that would improve service
accessibility for disabled persons – the list of
barriers is long, and while overcoming each ofthese examples would likely incur a cost, thearguably taller hurdle is in encouraging thenormative and structural shifts that are required
to effectively include marginalized people in thefirst place.
Meanwhile, failing to listen to, and tailor to,
the needs of these groups can incur a significant
cost – not only in the worsened health outcomesof marginalized groups but also in the form ofexpenses borne by health systems. For example,
many indigenous women in northern Canada
have historically preferred to give birth at homewith a midwife or other female caregiver – apractice that was restricted by health authorities
concerned about the safety of midwifery
practices. As a result, at 36 weeks of gestation,
pregnant women and adolescents in northernareas often had to be flown to urban facilities
with advanced services, incurring significant
costs. Today, midwifery is being reintroducedin the north, ensuring both modern obstetricalquality care and preservation of traditional
birthing preferences. Women who give birth
under the care of a midwife in Nunavut birthing
centres, for example, report lower stress levels,
greater involvement in decision-making andbetter psychosocial support compared to mothers

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who had to give birth in urban centres (Mikhail
and others, 2021). The best-intentioned
interventions, even those backed by abundantresources, do not, and cannot, achieve optimal
results unless they involve the individuals andcommunities affected.

services during pregnancy compared with those
who had not been to school (Islam, 2017).
Likewise, income status was a determinant of
whether indigenous women accessed maternal
health services, as was exposure to mass media
and their relationship with health workers (Akter
and others, 2018).

Inclusivity
Key to tailoring, as the previous several examples
highlight, is inclusive participation of thecommunities affected. But inclusivity is criticalbeyond the work of targeting communities andpopulations, and, for several reasons, it bears
consideration as a broader approach to sexualand reproductive health care.
Foremost among these reasons is that acommunity can appear collectively, topolicymakers and programme designers, as amonolith when nothing could be further fromthe case. Indigenous populations in countries
in every region of the world suffer from poorer
health outcomes, for example (Akter and others,2018). Yet these groups are extraordinarily
diverse, both within and between countries. They
often face intersecting forms of marginalization– including remote locations, poverty, challenges
communicating in national languages,
deprivation of education and discrimination
often linked to historical traumas. Despite such
similarities, each is unique, and the differences
matter when it comes to health service uptake
and acceptability.
Within a single indigenous group,socioeconomic differences can influence healthoutcomes, for example. In one study, indigenous
women with more education were 11 times
more likely to use maternal health services and23 times more likely to access antenatal care

122

The needs of indigenous communities canbe highly variable when it comes to sexualand reproductive health – a topic that is bothsensitive and deeply rooted in cultural norms.
Preferences for giving birth at home, with
one’s partner or with family members, can be
powerfully influenced by culture. Preference
for birthing positions can be cultural as well.
Some Quechua indigenous women in Peru,
for example, prefer vertical delivery using arope suspended from a ceiling, a practice nonstandard to medical practitioners in the country(Gabrysch and others, 2009). And, of course,
indigeneity is simply one example of how
inclusive design and community participation
are essential in creating sexual and reproductive
health system interventions – others’ needs
might vary based on migration status, caste,
disability, age or other factors.
Even more powerful than community
participation is community leadership.
Programmes, funding mechanisms and otherefforts to support community leadership are
growing, as is endorsement of this approach at
the highest levels. In the closing weeks of 2023,
for example, UNAIDS called for increasing
community leadership in disaggregated datacollection and in the provision of services for
HIV prevention, testing and treatment. Thisannouncement drew particular attention to theneed to reach transgender people, both withCHAPTER 5: Weaving a collective future

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data-collection efforts and with HIV services
tailored to needs as determined by transgendercommunities themselves. It was also notable forbeing the first time a Member State-led body
adopted a consensus decision with references andcommitments to transgender people (UNAIDS,
2023) – thereby affirming the necessity ofengaging with, and directing funding towards,
a community that remains among the moststigmatized and marginalized in the world.
The power of representation in decision-making
is well elaborated in studies of leadership quotas
for women, which show positive effects forgender equality broadly (O’Brien and Rickne,2016). An example in Chapter 3 further
illustrates the value of representation for healthoutcomes specifically: Increasing the numbersof female physicians and improving supportand respect for nurses and midwives has been
associated with improved health-care accessand health outcomes for women (see page 72).
Likewise, representation may be especiallycritical in the area of sexual and reproductive
health, where stigma is a frequent barrier to care
(Bohren and others, 2022).
More to the point, inclusion in decision-making
means redressing power imbalances – imbalancesthat may be invisible even to those who wield
power. Efforts to acknowledge and address
inequities and increase inclusion are often met
with counterclaims that they are discriminatory

Assuit is an ancient, intricate form of metal thread embroidery
traditionally practiced by women in northern Egypt. The Tally
Assuit Women's Collective (TAWC) is an intergenerationalgroup of artisans dedicated to keeping the craft alive. The
TAWC are a regular participant of the International Folk Art
Market. © Tally Assuit Women's Collective

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FEATURE

Ngäbe women spark a revolution
in women’s health and equality“It’s three hours walking,” 25-yearold Eneida says, offering a casualdescription of the arduous mountainhike she had completed well into her
ninth month of pregnancy to reachthe maternity waiting facility, or
casa materna.
Eneida lives in the remote Comarca
Ngäbe Buglé, a region inhabited by
the Ngäbe and Buglé indigenous
groups, located high in themountains of western Panama.
There are only a few paved roadsin the comarca, and they are pittedwith holes. Some residents travel byhorse. Most walk. Many pregnant
women give birth at home forthis reason. It is no coincidence
that the comarca has the highest
maternal death rate of any region in
the country.
Eneida chose to wait out the ﬁnal
days of her pregnancy at the Casa
Materna de San Félix, a maternity
waiting home that provides food,health care and transport to safedelivery services. “I like it. This placeis very nice,” she says.
The maternity waiting home is only
one of many sexual and reproductive
health services introduced to thecomarca thanks to the organizedefforts of the Ngäbe Women’s

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Association – a group that ﬁrst
convened 30 years ago with a very
different goal. Back then, in the
1990s, the women of the community
were seeking something else
entirely: a market for their crafts.
“We began meeting and identifying
our problems and our needs,” says
Gertrudis Sire, president of the
Ngäbe Women’s Association. It
quickly became clear some of thebiggest barriers to escaping poverty
were not economic – they werereproductive. “The women in thecommunity raised the problem thatthey had many children,” Ms. Sire
recalls. She explains that whenevera woman was unable to feed herchildren, she referred to the problem
as “July”, a reﬂection of how routine
it was. “‘I have a lot of July in myhouse,’ people used to say. What
is July? It was a way to identify thefamine that was in the community.
They said how can we avoid thatsituation? Have fewer children.”
Other sexual and reproductive
health needs also came to light.
“We noticed that women were dyingin their houses when giving birth.
There was no plan to transport thembecause within the region there wasno maternal and child hospital.” Theassociation approached the Ministryof Health and UNFPA, and together
they established a network of healthworkers to provide care and raiseawareness about maternal health,contraception and child nutrition.
Ms. Sire says, “We gave talks onthese topics, and they felt it, they
lived it.”
The mutually reinforcing relationshipbetween gender equality, sexual andreproductive health, and economic
empowerment was perhaps mostnotably recognized at the ICPD in
1994. But the experience of the
Ngäbe Women’s Association showsthat this realization was also taking
place in the most remote corners of
the world, as women began to plan
their families and invest in a better
future for themselves and theircommunities. The Ngäbe Women’s
Association worked independently
to unleash a virtuous cycle ofreproductive autonomy, improved
health and reduced poverty.
Eira Carrera, an interculturalinterpreter at the José Domingo
De Obaldía Maternal and Infant
Hospital, began her career as a healthpromoter in the comarca. “That was
in ’96, ’98,” she recalls. “The topics
we covered as health promoterswere sexual and reproductive
health, which involves sexually

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transmitted infections, Pap smears,
everything related to sexual andreproductive health, family planning…
domestic violence, even responsible
fatherhood.” The messages were
better received among women thanamong men. While the women weregenerally eager to beneﬁt from familyplanning – “because that was theirneed,” Ms. Carrera says – men wereless receptive. “Men did not want thisresource.”
There has been progress in thethree decades since. Asked if Ngäbe
women would say they make theirown decisions about contraception,
Ms. Carrerra says, “Out of 10 women,roughly 8 can say yes.” But there is
still a long way to go. The issue ofmachismo is greatly compoundedby persistent ethnic discrimination
facing the community. Not long ago,
Ngäbe community members were
expected to sit at the back of the bus
when travelling outside the comarca.
Even today, job opportunities are
scarce, and many Ngäbe men
survive as migrant labour forcoffee plantations.
For women, this overlap between
ethnic marginalization and genderinequality continues to be deadly.
“The majority of maternal deaths are
speciﬁcally because the husband
has not been able to take his wife to
get care,” says Humberto Rodríguez,
a nurse in charge of the Nole DuimaDistrict, describing deaths among
women whose husbands weretravelling when they went into labour.
“The husband is not at home atthat moment, and the decision is
not hers.”

Eira Carrera ensures Ngäbe women are heard and respected in the health system.
She also teaches them about their rights. © UNFPA/Rebecca Zerzan

Ngäbe women used to bedisempowered by health systems as
well, Ms. Carrera says. “Doctors took
the ﬁle, treated the woman and if she
refused, the woman did not receive
the care she needed or she received
it in a forced, obligatory manner thatwould violate her rights… Today, thathas totally changed.” Ms. Carrera
now interprets between the healthstaff, who speak Spanish, and thepatients, who speak Ngäbe. She also
trains hospital personnel to engage
in a culturally sensitive way. Women
treated with dignity and information
will often consent to care, Ms.
Carrera says. “If she does not accept,that is respected.”
She wants women to understandbodily autonomy extends to theirrelationships, as well. “I give a talkhere to mothers, saying you are notobliged to have sexual relations withyour husband against your will. Thisis called sexual abuse,” Ms. Carrera

explains. “We still have to work a loton that.”
But these issues are not uniqueto the Ngäbe community, Ms. Sireemphasizes. “The problem iseverywhere,” she says. “There will
always be this machismo thing…
and discrimination will never end,
because that is everywhere… But
people like us in the Association, we
have been trained by it. We alreadyhave an armour.”Eneida, the woman awaiting thebirth of her third child, has such anarmour – though she is open andsmiling rather than defensive. Herarmour is her conﬁdence. Asked
whether her partner would support
her decision about family planning,
there is no question: “Yes. Yes. I will
be supported. Yes,” Eneida says.
“With whatever I want.”

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to those with institutional and historicaladvantages (Pierce, 2013). This adversarial
framing of inclusivity is counterproductive –not only for the disadvantaged but often forsociety as a whole. After all, gender equality
benefits not only women and girls but men
and boys as well, on measures ranging fromfinancial stability (Ozili, 2024) to better healthand life satisfaction (Wells and others, 2024).
The Lancet Commission on Peaceful Societies
through Health Equity and Gender Equality
notes that “improvements in health equity andgender equality [can] strengthen human capital,
the inclusiveness of economies, social capital,
and governance" (Lancet Commission on
Peaceful Societies Through Health Equity andGender Equality, 2023). Efforts to achieve equity
through inclusion can also be expected to benefit
society more broadly.

Comprehensive and universal
Building upon previous decades of research
and agreement, the SDGs call for sexualand reproductive health services to be bothcomprehensive and universal. These are not novel
concepts – but what is new, or newer, is growing
optimism that both are readily achievable.
Comprehensiveness has been well elaborated
by WHO in its guidance note on reproductive
health, which defines a comprehensive packageof reproductive health care as one including
a wide range of services for contraception;antenatal, childbirth and postnatal care; safe
abortion services and treatment of complicationsof unsafe abortion; prevention and treatment of
HIV and other sexually transmitted infections;and services to address gender-based violence.
In addition, health promotion is essential,
including through provision of information and126

counselling for everyone on sexual health andwell-being and, for young people, comprehensive
sexuality education (WHO, 2023).
Universal health coverage, too, has been wellarticulated within the international community.
SDG 3.8 calls for achieving “universal healthcoverage, including financial risk protection,access to quality essential health-care services andaccess to safe, effective, quality and affordable
essential medicines and vaccines for all”
(UN DESA, 2023).
Still, both comprehensiveness and universality
have been elusive, with persistent gaps incoverage negatively impacting the marginalized
most of all. But where comprehensivenessor universality have been achieved, or nearly
achieved, the contributions to equity have been
notable. One report to the Human Rights
Council, for instance, noted that universal healthcare is likely to have mitigated racial disparities
in some countries (Human Rights Council,2020). (In fact, one of the central aims of
universal health coverage is equity in access.)
Further, significant progress has been seen
in many countries, underlining how readily
achievable this goal truly is. Peru, for example,
experienced a decade of extraordinary growth
in reproductive health coverage starting in
2007, when the country launched a resultsbased budget initiative that allocated funds tomaternal and neonatal health and child nutrition(Huicho and others, 2018). The programme
relied primarily on domestic expenditures, with
development assistance as a minor componentof the financial support, and the results
included major reductions in under-five andneonatal mortality.

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Advances are possible even if countries areunable to adopt a full package of universal andcomprehensive sexual and reproductive healthinterventions at the same time. In 2020, forexample, Zambia adopted a universal healthcoverage plan that includes contraceptive
supplies and services – aplan that is universal if not
yet comprehensive for all
reproductive health services(PAI, 2020).
Importantly, universality mustmean everyone. This may
seem self-evident, but mostcountries persist in viewing
universal health coverage as thegoal of providing health care
to all citizens. This excludes
some of those most in need:
undocumented migrants,
temporary migrant workers,
stateless persons and refugees,
among others. As one studyof the conundrum puts it, theworld’s health experts have“declared that ‘all roads lead touniversal health coverage’ yet
undocumented migrants do nottravel those roads” (Onarheim
and others, 2018). Consideringthat a mass movement of people
across borders is possible in the
coming years, this could lead toan ever-expanding populationof people excluded from healthcare. In addition to supporting
the fundamental human rightto health, extending health care
In KwaZulu-Natal, South Africa, ayarn-bombed tree raises awarenessfor communities affected by HIV/AIDS.
© Paula Thompson/Woza MoyaS TAT E O F W O R L D P O P U L AT I O N 2024

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to all people within a country’s borders canhave public health and economic benefits. One
study compared two high-income countries,
Norway and the United States, that do notprovide coverage for undocumented migrants,
and one middle-income country, Thailand,
which does; it concluded that Thailand’s
health approach is less “problematic” and more
likely to achieve the SDG goal on universal
health coverage (Onarheim and others, 2018).
Other research suggests that providing healthinsurance for undocumented migrants could
lead to lower health-care costs as a result of
overall improvements in population health(Gostin, 2019).
And the issue of costs is, indeed, a central
consideration for all countries. Today, developing
countries are grappling with unprecedented
levels of international debt, due to factors
ranging from “the pandemic, a situation
compounded by inflation, rising interest rates,
trade tensions and constrained fiscal capacity”(UN DESA, 2023). Large interest payments
are already affecting health-care spending in 48
developing countries that are home to 3.3 billion
people. The average low-income country now
spends 1.4 times more on net interest payments
than on domestic health expenditures. Highincome countries, by contrast, spend almost
four times more on health care than on net
interest payments (UNDP, 2023). There are,however, highly promising and innovative formsof health finance emerging that could bringquality, universal health coverage within reach,such as sovereign bonds tied to achieving specifichealth outcomes. Equally important is agreement(reinforced during the pandemic) that universal
health coverage is both a moral and publichealth imperative. As the Managing Director

128of the International Monetary Fund Kristalina
Georgieva said in December 2020, “One thingis clear: We will not go back to where we were.
If we are to overcome the crisis and shape therecovery, we must move forward with a renewed
sense of purpose and solidarity – with all people”(Georgieva, 2020).

Expanding accurate reproductive
health knowledge
Empowering people to take charge of their own
health through information and knowledge
is as critically important as universal andcomprehensive health care. This is especiallytrue for marginalized groups, including young
people. It will only become more important astechnologies advance, countries’ demographic
profiles change and health systems evolve.
One of the main tools for expanding
reproductive health knowledge is comprehensive
sexuality education, the efficacy and benefits ofwhich are elaborated in Chapter 4. In addition
to generating individual and societal returns on
investment in terms of health, education andproductivity, comprehensive sexuality education
can also strengthen the agency and capacityof marginalized youth. For example, research
indicates quality, age-appropriate, rights-based
comprehensive sexuality education can foster ayoung person’s sense of power, autonomy andbelief in their own equality, as it “seeks explicitly
to empower young people – especially girls
and other marginalized young people – to seethemselves and others as equal members in theirrelationships, able to protect their own health,and as individuals capable of engaging as active
participants in society” (Haberland and Rogow,2015). In other words, effective comprehensive
sexuality education can help young people reflect

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3/28/24 11:18 AMcritically about inequalities, including genderinequality, leading to more equitable decisions
and behaviours. Despite this, support forcomprehensive sexuality education has falteredin recent years (United Nations, 2023a).
And comprehensive sexuality education is only
one way to expand access to accurate, quality
reproductive health knowledge. Anotherrequires removing outdated, biased, inaccurate
or overly simplified information from not only
textbooks but also medical education curricula,
health systems and reproductive health policies.
As Chapter 2 highlights, misinformation,
partial information and oversimplification
have had adverse impacts on marginalized
people throughout history and continue todo so today.
Failure to equip people – adolescents, healthprofessionals, policymakers and everyone in
between – with factual, unbiased information
can only lead to societies that are ill equipped
to address the concerns of the future. Global
health systems are embracing self-careinterventions as an increasingly critical tool“for every country and economic setting, as a
critical path to reach universal health coverage,
promote health, keep the world safe, andserve the vulnerable” (WHO, n.d.d). Selfcare interventions are particularly critical forsexual and reproductive health, where barriers
to services include not only access to healthfacilities but also stigma and patriarchal norms.
But for those most left behind to effectively
benefit from self-care, they require accurate
health information (UNFPA, 2018a).
Expanding reproductive health knowledge
also means investing in the development of

inclusive health information and interventions.
Health-care research continues to treat men,and especially men in high-income countries, as
default patients and research subjects. Researchand development funding for maternal healthconcerns fell by 15 per cent between 2018 and
2021, for example, a fact researchers attributeto the disproportionate concentration of theseissues in low- and middle-income countries(Policy Cures Research, 2023). Women are
estimated to spend 25 per cent more time indebilitating health than men, yet they remain
underrepresented or inaccurately represented
within medicine: “To understand basic female
biology better, fundamentally new researchtools should be developed (for example, animalmodels, computational models, patient avatars
and humanized models) that better classify
women’s symptoms and manifestations ofdisease (as opposed to calling those ‘atypical’),”a recent paper asserts (World Economic
Forum, 2024). Investments that close thewomen’s health gap “would potentially boost
the economy by at least $1 trillion annuallyby 2040”.
Solutions will also be required to resolve
questions over ethically thorny advances in
reproductive medicine and digital tools thatare both promising and also, at the sametime, potential threats to privacy and safety.
Humanity’s ability to rise to these challenges
is greatly undermined when we cannot
agree on the facts of human development,
reproduction, anatomy, sexuality and diversity.
All people have the right to up-to-date,scientifically accurate, culturally sensitive,
age-appropriate sexual and reproductive healthknowledge – there should be nothing politicalor controversial about it.

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Celebrate the gains,and commit to more
The evidence brought to light shows that theachievements since 1994 have been many but
they must go further. Time and again, the world
has seen that efforts to eliminate poor healthoutcomes and end preventable maternal deaths
are simply not enough to overcome the barriers
posed by inequality, discrimination, bias andstigma. Yet this fact offers us perhaps the best
chance of achieving our agreed goals – thosefrom both the ICPD and the 2030 Agenda – torealize the rights and choices of all people.
The recent past has been one of historic
disruptions, disruptions that triggered calls forjustice, inspired new thinking about systemic
inequities, and mobilized advocacy around theworld. Indeed, when we widen the lens, zooming
out from the recent past to the last 30 years, we
see far more reasons for hope than despair.
Lack of data, and especially disaggregated data, isan enormous hindrance, as detailed throughout
this report – but the data we do have today, andthe methods available to analyse them, are better
than ever before. We must build on these gains.
Milestone achievements – like SDG indicators
5.6.1 and 5.6.2, which stand as some of theworld’s first-ever measures of bodily autonomy
and enabling legal environments – are just thefirst steps towards measuring and understanding
the state of women’s reproductive agency.
Systems must be reformed to eliminate
embedded and invisible forms of discrimination,a process that is likely to cause debate anddiscontent – yet the process has already begun,

130with the Ni Una Menos and MeToo movements
exposing gendered power imbalances andmovements such as Rhodes Must Fall and Black
Lives Matter highlighting racial inequities.
Political will is needed to direct more resources
towards the sexual and reproductive health andrights of marginalized groups, seemingly a tallorder in an increasingly polarized, politicizedworld – yet there are encouraging signs thatpolicymakers are willing to address many of theseissues head-on. In the 2023 voluntary national
reviews (a process in which Member States
voluntarily identify sustainable development
priorities and efforts on the ground as part of the2030 Agenda for Sustainable Development), allof the 39 participating Member States addressedgroups affected by marginalizing factors such as
gender and disability, people in rural or remoteareas and ethnic minorities. Just under half,
49 per cent, addressed the needs of LGBTQIA+
persons (UNFPA, 2024g). While the reviews do
not necessarily reflect on-the-ground change,
they are a critical step towards transparency inStates’ policy positions and priorities (FukudaParr and others, 2018). Strong advocacy,
and follow-up, could therefore go a long way
towards putting the sexual and reproductive
health of marginalized people high on thedevelopment agenda.
The issue of power must also be addressed.
Policies, attitudes and norms around the worldperpetuate inequities at levels both high andlow – but change is possible, and imminent.
In fact, this year will represent a milestone forelections, with more than 2 billion voters set
to go to the polls in more than 50 countries(World Economic Forum, 2023). Voting matters
because, as this report highlights, representation

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does. This is why the world agreed
to SDG 5.5.1, which measures the
proportion of seats held by womenin national parliaments and local
governments. Voting can help lift
up the voices of other vulnerable
and marginalized people, as well.
And while elections and public
advocacy are necessary tools forending marginalization, it mustalso be acknowledged that thesetools simply do not exist in too
many countries. In these cases,
international standards bodies
such as those of the United
Nations must speak up andemphasize that the adoption of
the SDG targets and the many
human rights instruments thatreinforce them are obligationsof all Member States, producedwith the agreement of thosevery governments, that must
be implemented.
Finally, the voices of the marginalized growlouder every day. Rather than respond withalarm, we can meet their appeals with openness
and collaboration. Impatience with what wehave yet to achieve is justifiable and can evenbe welcomed. It is a mark of progress that
we can identify and grapple with the forcesthat continue to push people behind. There is
progress, too, in the fact that our expectations ofhealth, rights and fairness have shifted in the past
three decades. The world has changed; standards
are higher. So, too, is our ability to deliver.

In the end, achievement of the world’s mostlofty goals will mean little if we insist upon
the simplest ways of tallying progress, withwhole countries, communities and identities
swallowed into a global average. We arecapable of a more sophisticated vision, one that
acknowledges the dignity and value of every
individual, one which recognizes that assuring
the rights of all people means securing therights of each person. After all, the fabric of
humanity is vast and beautiful, but it is only as
strong as its most fragile thread.

S TAT E O F W O R L D P O P U L AT I O N 2024

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Pankaja Sethi’s artwork "The Flaming Womb" examines the gap between the symbolic attributes of womanhood and the role andconditions of women as dictated by a patriarchal society. The piece was included as part of the Fabric of Being exhibition curated
by SEA Junction for the Nairobi Summit on ICPD25, in 2019. © Pankaja Sethi

132

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Indicators
Tracking progress towards ICPD goals:
Sexual and reproductive healthpage 134

Tracking progress towards ICPD goals:
Gender, rights and human capital

page 140

Demographic indicators

page 146

Technical notes

page 152

S TAT E O F W O R L D P O P U L AT I O N 2024

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133

3/28/24 11:18 AM 

Sexual and reproductive healthMaternal
Range
Range
Births attended
mortalityof MMRof MMRby skilled healthratio (MMR) uncertainty uncertainty
personnel,(deaths per (UI 80%),(UI 80%),per cent
100,000 live
lower
upper
births)aestimatea
estimatea

Number of
new HIV
infections,
all ages,per 1,000
uninfected
population

Contraceptive prevalence rate,
women aged 15–49, per centAny method
All

Married
or in
union

Unmet need forfamily planning,
women aged
Modern method 15–49, per centAll

Married
or in
union

All

Proportionof demandsatisﬁedwith modern
methods, all
Married women aged
or in
15–49
union

Laws and regulations
that guarantee
access to sexual andreproductive healthcare, information andeducation, per cent

Universal
healthcoverage(UHC)
servicecoverageindex

Countries,
territories,
other areasWorldand regional
areas

2020

2020

2020

2004–2022
2022

2022

2024

2022

2021

World

223

202

255

86

0.17

50

65

46

59

9

11

78

76

68

More developed regions

12

10

14

99

0.15

58

70

52

62

7

8

80

87

84

Less developed regions

244

221

279

81

0.17

49

65

45

59

9

11

77

72

64

Least developed countries

377

338

431

65

0.34

33

43

29

38

15

20

61

71

44

Arab States

145

110

194

83

0.04

34

53

29

45

10

15

66

65

61

Asia and the Paciﬁc

113

101

128

87

0.07

54

71

50

65

6

8

82

74

68

Eastern Europe and Central Asia

21

19

25

98

0.15

46

64

36

49

8

11

67

84

74

2024

2024

2024

UNFPA regions

Latin America and the Caribbean

88

79

99

95

0.19

59

75

56

71

8

9

83

75

76

East and Southern Africa

360

313

441

70

0.83

36

45

33

42

15

20

65

72

46

West and Central Africa

750

625

986

61

0.30

21

23

18

20

17

22

47

70

40
2021

Countries, territories, other areas

2020

2020

2020

2004–2022

2022

2024

2022

Afghanistan

620

406

1050

62

0.03

21

29

19

26

17

23

50

56

41

8

4

16

100

0.02

33

45

6

6

12

16

12

79

64

Albania

2024

2024

2024

Algeria

78

41

164

99

0.05

35

60

30

52

7

11

72

–

74

Angola

222

148

330

50

0.44

17

18

16

17

26

35

37

62

37

Antigua and Barbuda

21

11

36

99

–

42

63

40

61

10

13

77

–

76

Argentina

45

38

53

99

0.09

59

71

57

68

10

11

83

92

79
68

Armenia

27

19

42

100

0.19

39

60

22

33

8

12

46

87

Aruba

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Australia

3

2

4

96

–

59

67

57

64

8

10

85

–

87

Austria

5

4

8

98

–

66

73

64

71

5

7

89

–

85

Azerbaijan

41

22

69

100

0.05

37

58

16

24

9

13

35

–

66

Bahamas

77

51

128

99

0.15

46

66

44

65

10

12

79

–

77

Bahrain

16

13

19

100

–

29

63

20

44

5

12

59

73

76

Bangladesh

123

89

174

59

0.01

52

64

45

56

9

11

74

–

52

Barbados

39

22

61

98

0.21

51

63

47

60

12

14

75

44

77

Belarus

1

1

2

100

0.11

54

63

47

53

11

11

72

83

79

Belgium

5

4

6

–

0.04

59

67

58

67

6

8

91

–

86

Belize

130

105

161

95

0.35

46

58

43

54

14

17

72

43

68

Benin

523

397

768

78

0.11

18

20

15

16

24

30

36

91

38

Bhutan

60

40

82

99

0.08

40

62

39

60

8

12

81

83

60

Bolivia (Plurinational State of)

161

103

272

81

0.16

49

68

37

51

11

15

61

94

65

6

4

8

100

–

39

51

20

22

9

13

42

70

66

Botswana

186

151

230

100

1.92

59

70

58

70

8

10

87

64

55

Brazil

72

57

93

98

0.24

67

80

65

78

6

7

90

–

80

Brunei Darussalam

44

30

61

100

–

–

–

–

–

–

–

–

41

78

Bulgaria

7

5

10

95

0.03

66

81

52

60

5

6

73

62

73

Burkina Faso

264

169

394

96

0.08

30

34

29

33

19

23

60

81

40

Burundi

494

353

694

77

0.10

21

34

18

31

16

27

51

65

41

Cabo Verde

42

26

65

97

0.34

45

59

44

58

12

15

77

84

71

Cambodia

218

156

326

99

0.08

43

65

33

49

7

10

65

98

58

Cameroon

438

332

605

69

0.36

24

24

20

19

16

21

51

–

44

Bosnia and Herzegovina

134

Indicators

swp2024-english-240327.indd 134

3/28/24 11:18 AM 

Sexual and reproductive healthMaternal
Range
Range
Births attended
mortalityof MMRof MMRby skilled healthratio (MMR) uncertainty uncertainty
personnel,(deaths per (UI 80%),(UI 80%),per cent
100,000 live
lower
upper
births)aestimatea
estimatea

Number of
new HIV
infections,
all ages,per 1,000
uninfected
population

Contraceptive prevalence rate,
women aged 15–49, per centAny method
All

Married
or in
union

Unmet need forfamily planning,
women aged
Modern method 15–49, per centAll

Married
or in
union

All

Proportionof demandsatisﬁedwith modern
methods, all
Married women aged
or in
15–49
union

Laws and regulations
that guarantee
access to sexual andreproductive healthcare, information andeducation, per cent

Universal
healthcoverage(UHC)
servicecoverageindex

Countries, territories, other areas

2020

2020

2020

2004–2022

2022

2024

2022

2021

Canada

11

9

15

98

–

73

82

71

80

3

4

92

–

91

Central African Republic

835

407

1519

40

1.57

22

24

17

19

21

25

40

77

32

Chad

1063

772

1586

47

0.22

8

9

7

8

19

25

27

59

29

2024

2024

2024

Chile

15

13

17

100

0.25

65

78

60

72

6

8

85

–

82

China

23

19

27

100

–

71

85

69

83

4

3

92

–

81

China, Hong Kong Special
Administrative Region

–

–

–

–

–

49

71

46

68

8

9

81

–

–

China, Macao Special
Administrative Region

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Colombia

75

65

86

99

0.16

65

82

61

77

5

6

87

96

80

Comoros

217

131

367

82

0.00

21

29

17

24

19

29

44

–

48

Congo

282

194

429

91

2.89

43

46

31

30

14

18

54

55

41

Costa Rica

22

18

26

99

0.14

57

74

56

72

9

10

84

84

81

Côte d'Ivoire

480

318

730

84

0.31

27

26

23

23

21

26

49

64

43

Croatia

5

3

7

100

0.02

50

71

36

47

5

8

65

98

80

Cuba

39

35

44

100

0.18

69

72

68

71

8

9

88

–

83

Curaçao

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Cyprus

68

47

99

99

–

–

–

–

–

–

–

–

72

81

Czechia

3

2

5

100

0.02

62

85

55

76

4

4

84

79

84

Democratic People's Republic of Korea

107

46

249

100

–

61

75

58

72

8

8

85

83

68

Democratic Republic of the Congo

547

377

907

85

0.13

27

31

17

17

20

25

36

–

42

Denmark

5

4

6

95

0.01

64

77

61

73

5

6

88

87

82

Djibouti

234

105

530

87

–

17

32

17

31

14

25

54

–

44
49

Dominica

–

–

–

100

–

46

64

44

62

10

13

78

–

Dominican Republic

107

87

133

99

0.37

55

68

53

66

10

13

82

–

77

Ecuador

66

52

86

99

0.11

59

80

54

73

7

6

82

92

77

Egypt

17

13

22

97

0.05

45

62

43

60

9

12

81

–

70

El Salvador

43

31

61

100

0.13

53

74

50

69

8

10

82

92

78

Equatorial Guinea

212

122

374

68

2.94

19

19

16

16

22

31

39

–

46

Eritrea

322

207

508

34

0.06

9

15

9

14

15

28

35

–

45

Estonia

5

3

9

100

0.10

58

71

50

60

5

7

78

98

79

Eswatini

240

147

417

88

4.10

53

69

52

68

9

12

84

98

56

Ethiopia

267

189

427

50

0.08

31

42

30

41

15

20

67

73

35

Fiji

38

28

55

100

0.33

35

51

30

44

12

16

65

–

58

Finland

8

6

13

100

–

79

82

74

77

3

4

91

98

86

France

8

6

10

98

0.09

66

78

64

76

4

4

91

–

85

French Guiana

–

–

–

–

–

–

–

–

–

–

–

–

–

–

French Polynesia

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Gabon

227

141

383

89

0.83

39

39

31

29

18

23

55

58

49

Gambia

458

333

620

84

0.60

15

21

14

20

16

24

46

–

46

Georgia

28

22

33

100

0.14

33

48

24

35

13

18

53

94

68

Germany

4

4

5

96

–

55

68

54

67

7

9

88

87

88

Ghana

263

180

376

79

0.53

27

36

24

32

19

26

52

66

48

Greece

8

5

12

100

0.08

53

75

39

52

5

7

68

72

77

Grenada

21

12

34

100

–

47

65

44

61

10

12

77

–

70

S TAT E O F W O R L D P O P U L AT I O N 2024

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135

3/28/24 11:18 AM 

Sexual and reproductive healthMaternal
Range
Range
Births attended
mortalityof MMRof MMRby skilled healthratio (MMR) uncertainty uncertainty
personnel,(deaths per (UI 80%),(UI 80%),per cent
100,000 live
lower
upper
births)aestimatea
estimatea

Number of
new HIV
infections,
all ages,per 1,000
uninfected
population

Contraceptive prevalence rate,
women aged 15–49, per centAny method
All

Married
or in
union

Unmet need forfamily planning,
women aged
Modern method 15–49, per centAll

Married
or in
union

All

Proportionof demandsatisﬁedwith modern
methods, all
Married women aged
or in
15–49
union

Laws and regulations
that guarantee
access to sexual andreproductive healthcare, information andeducation, per cent

Universal
healthcoverage(UHC)
servicecoverageindex

Countries, territories, other areas

2020

2020

2020

2004–2022

2022

2024

2022

2021

Guadeloupe

–

–

–

–

–

40

59

37

53

10

15

73

–

–

Guam

–

–

–

–

–

37

66

32

56

7

10

74

–

–

Guatemala

96

85

106

70

0.07

43

65

37

55

9

12

72

–

59

Guinea

553

404

808

55

0.43

15

15

14

14

18

23

43

79

40

Guinea-Bissau

725

475

1135

54

0.59

32

24

31

24

16

19

63

80

37

Guyana

112

83

144

98

0.62

30

39

29

38

20

28

57

87

76

Haiti

350

239

550

42

0.58

29

40

27

37

23

33

52

65

54

Honduras

72

58

91

94

0.05

51

73

47

67

8

10

80

80

64

Hungary

15

11

21

100

–

50

70

45

63

7

9

80

93

79

Iceland

3

1

4

97

0.04

–

–

–

–

–

–

–

–

89

India

103

93

110

89

0.05

51

68

45

60

6

9

78

74

63

Indonesia

173

121

271

95

0.09

44

63

42

60

8

11

82

77

55

Iran (Islamic Republic of)

22

14

32

99

0.03

58

82

47

66

3

4

77

63

74

Iraq

76

50

121

96

0.01

38

57

27

41

8

12

59

59

59

Ireland

5

4

7

100

–

65

70

63

66

6

9

89

–

83

Israel

3

2

4

–

–

41

73

32

56

5

8

69

–

85

Italy

5

4

6

100

0.04

60

67

49

52

6

9

75

–

84
74

2024

2024

2024

Jamaica

99

80

122

100

0.50

44

73

42

70

9

9

79

76

Japan

4

3

6

100

–

47

53

41

42

12

17

69

85

83

Jordan

41

26

62

100

0.00

31

55

23

40

8

14

58

56

65

Kazakhstan

13

10

18

100

–

43

54

40

51

10

14

76

65

80

Kenya

530

382

750

70

0.46

49

65

47

63

11

14

78

48

53

Kiribati

76

33

146

92

–

24

32

20

27

17

23

49

–

48

Kuwait

7

5

11

100

–

36

60

30

50

8

13

68

–

78
69

Kyrgyzstan

50

37

70

100

0.11

29

43

28

40

12

17

68

73

Lao People's Democratic Republic

126

92

185

64

0.14

39

62

35

55

9

13

72

96

52

Latvia

18

14

25

100

0.19

59

72

52

62

6

8

81

70

75

Lebanon

21

18

24

98

–

33

62

25

47

7

12

63

–

73

Lesotho

566

385

876

87

3.03

52

67

51

67

9

13

84

–

53

Liberia

652

499

900

84

0.24

28

28

27

27

25

31

51

–

45

Libya

72

31

165

100

–

25

41

17

27

15

25

41

–

62

Lithuania

9

5

14

100

0.06

48

72

40

58

6

8

74

87

75

Luxembourg

6

4

12

100

0.06

–

–

–

–

–

–

–

–

83

Madagascar

392

311

517

46

0.30

42

53

38

47

13

14

69

–

35

Malawi

381

269

543

96

0.81

50

67

49

66

12

14

79

79

48

Malaysia

21

18

29

100

0.09

36

58

26

42

9

14

59

83

76

Maldives

57

40

83

100

0.01

18

24

14

19

22

29

36

93

61

Mali

440

335

581

67

0.28

19

21

19

21

21

24

47

–

41

Malta

3

2

5

100

0.09

61

79

50

63

4

5

76

–

85

Martinique

–

–

–

–

–

41

61

38

56

10

14

74

–

–

Mauritania

464

337

655

70

0.12

10

14

9

13

22

32

30

65

40

Mauritius

84

62

115

100

–

44

67

30

46

7

9

59

75

66

Mexico

59

46

74

97

0.16

55

74

53

71

9

10

82

86

75

Micronesia (Federated States of)

74

32

169

100

–

–

–

–

–

–

–

–

–

48

136

Indicators

swp2024-english-240327.indd 136

3/28/24 11:18 AM 

Sexual and reproductive healthMaternal
Range
Range
Births attended
mortalityof MMRof MMRby skilled healthratio (MMR) uncertainty uncertainty
personnel,(deaths per (UI 80%),(UI 80%),per cent
100,000 live
lower
upper
births)aestimatea
estimatea

Number of
new HIV
infections,
all ages,per 1,000
uninfected
population

Contraceptive prevalence rate,
women aged 15–49, per centAny method
All

Married
or in
union

Unmet need forfamily planning,
women aged
Modern method 15–49, per centAll

Married
or in
union

All

Proportionof demandsatisﬁedwith modern
methods, all
Married women aged
or in
15–49
union

Laws and regulations
that guarantee
access to sexual andreproductive healthcare, information andeducation, per cent

Universal
healthcoverage(UHC)
servicecoverageindex

Countries, territories, other areas

2020

2020

2020

2004–2022

2022

2024

2022

2021

Mongolia

39

28

55

99

0.01

42

58

38

53

12

15

71

–

65

Montenegro

6

3

11

99

0.02

23

27

16

17

15

21

43

52

72

Morocco

72

51

96

87

0.02

43

71

37

62

7

10

75

–

69

Mozambique

127

99

157

73

3.20

29

33

28

31

18

21

60

–

44

Myanmar

179

125

292

60

0.21

35

59

34

58

8

13

80

91

52

Namibia

215

154

335

88

2.39

53

62

53

61

10

14

84

88

63

Nepal

174

125

276

77

0.02

42

55

37

49

15

21

65

48

54

Netherlands (Kingdom of the)

4

3

6

–

–

63

72

61

70

5

7

89

100

85

New Caledonia

–

–

–

–

–

–

–

–

–

–

–

–

–

–

New Zealand

7

5

9

97

0.01

65

81

61

75

5

5

88

95

85

2024

2024

2024

Nicaragua

78

54

109

94

0.08

59

82

57

79

6

6

88

75

70

Niger

441

305

655

44

0.06

12

15

12

14

16

20

41

–

35

Nigeria

1047

793

1565

51

–

18

21

14

16

15

19

43

–

38

North Macedonia

3

1

6

100

0.03

44

54

21

21

9

13

40

–

74

Norway

2

1

3

99

–

66

85

61

79

3

3

89

100

87

Oman

17

12

25

100

0.03

22

37

16

26

14

25

43

70

70

Pakistan

154

109

226

68

–

27

40

20

31

11

17

54

69

45

Panama

50

46

54

95

0.32

49

61

46

57

14

17

74

72

78

Papua New Guinea

192

126

293

56

0.65

28

39

24

33

17

24

52

–

30

Paraguay

71

60

82

92

–

60

73

56

68

8

8

83

76

72

Peru

69

59

80

95

0.17

51

77

40

58

5

6

71

85

71

Philippines

78

67

96

84

0.21

36

58

27

44

10

15

60

80

58

Poland

2

1

3

100

–

54

74

44

59

6

7

73

89

82

Portugal

12

8

18

99

0.06

59

74

51

63

5

7

79

95

88

Puerto Rico

34

25

54

–

–

51

82

47

74

7

5

81

–

–

Qatar

8

5

11

100

0.04

33

50

28

42

10

15

65

71

76

Republic of Korea

8

7

9

100

–

56

81

51

74

6

5

82

–

89

Republic of Moldova

12

9

17

100

0.34

49

59

40

47

12

15

65

–

71

Réunion

–

–

–

–

–

52

72

50

71

8

9

84

–

–

Romania

10

7

14

93

0.03

54

71

46

59

6

8

76

98

78

Russian Federation

14

9

20

100

–

49

68

42

58

7

9

75

70

79

Rwanda

259

184

383

94

0.24

40

67

37

61

9

12

76

82

49

Saint Kitts and Nevis

–

–

–

100

–

49

61

46

57

12

14

76

–

79

Saint Lucia

73

44

127

100

–

49

61

46

58

12

14

76

33

77

Saint Vincent and the Grenadines

62

40

92

99

–

51

67

49

64

10

12

80

81

69

Samoa

59

26

137

89

–

14

22

13

20

28

42

32

22

55

San Marino

–

–

–

–

–

–

–

–

–

–

–

–

–

77

Sao Tome and Principe

146

74

253

97

0.06

38

51

36

48

20

24

61

46

59

Saudi Arabia

16

11

22

95

0.04

21

33

18

27

15

24

49

–

74

Senegal

261

197

376

75

0.09

22

31

21

30

14

21

58

75

50

Serbia

10

8

14

100

0.02

49

59

29

29

7

11

51

99

72

Seychelles

3

3

4

100

–

–

–

–

–

–

–

–

–

75

Sierra Leone

443

344

587

87

0.44

28

27

28

26

19

24

58

65

41

Singapore

7

5

11

100

–

40

69

36

61

6

10

78

46

89

S TAT E O F W O R L D P O P U L AT I O N 2024

swp2024-english-240327.indd 137

137

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Sexual and reproductive healthMaternal
Range
Range
Births attended
mortalityof MMRof MMRby skilled healthratio (MMR) uncertainty uncertainty
personnel,(deaths per (UI 80%),(UI 80%),per cent
100,000 live
lower
upper
births)aestimatea
estimatea

Number of
new HIV
infections,
all ages,per 1,000
uninfected
population

Contraceptive prevalence rate,
women aged 15–49, per centAny method
All

Married
or in
union

Unmet need forfamily planning,
women aged
Modern method 15–49, per centAll

Married
or in
union

All

Proportionof demandsatisﬁedwith modern
methods, all
Married women aged
or in
15–49
union

Laws and regulations
that guarantee
access to sexual andreproductive healthcare, information andeducation, per cent

Universal
healthcoverage(UHC)
servicecoverage
index
2021

Countries, territories, other areas

2020

2020

2020

2004–2022

2022

2024

2022

Sint Maarten (Dutch part)

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Slovakia

5

3

6

98

0.02

55

79

47

67

5

6

79

86

82

Slovenia

5

3

7

100

–

52

79

44

67

4

5

79

–

84

2024

2024

2024

Solomon Islands

122

75

197

86

–

24

33

20

27

13

18

54

–

47

Somalia

621

283

1184

32

–

8

10

2

2

17

26

9

–

27

South Africa

127

99

154

97

3.15

52

59

51

59

11

14

82

95

71

South Sudan

1223

746

2009

40

0.79

7

9

6

8

21

29

23

16

34

Spain

3

3

4

100

–

62

64

60

62

7

12

87

–

85

Sri Lanka

29

24

38

100

0.01

45

68

37

56

5

7

74

86

67

State of Palestine1

20

15

26

100

–

40

62

30

47

7

10

64

68

–

Sudan

270

174

420

78

0.09

12

17

11

16

17

27

37

57

44

Suriname

96

70

128

98

0.76

35

49

35

48

14

21

70

–

63

Sweden

5

3

6

–

–

59

71

56

68

6

8

87

100

85

Switzerland

7

5

11

–

–

73

73

68

68

4

7

89

94

86

Syrian Arab Republic

30

19

47

96

0.00

34

63

26

47

7

12

63

81

64

Tajikistan

17

9

31

95

0.10

25

34

23

31

16

21

57

–

67

Thailand

29

24

34

99

0.13

49

77

48

75

4

6

90

–

82

Timor-Leste

204

147

283

57

0.07

20

34

18

31

13

22

55

–

52

Togo

399

253

576

69

0.28

25

28

23

26

22

30

49

–

44

Tonga

126

55

289

98

–

20

34

17

29

14

25

50

–

57

Trinidad and Tobago

27

19

36

100

–

41

50

37

46

14

19

66

27

75

Tunisia

37

24

49

100

–

33

60

29

51

8

12

70

–

67

Türkiye

17

13

23

97

–

48

72

33

50

6

9

62

78

76

Turkmenistan

5

3

9

100

–

36

54

33

50

8

12

77

94

75

Turks and Caicos Islands

–

–

–

100

–

37

39

36

38

19

23

64

–

–

Tuvalu

–

–

–

100

–

20

27

18

24

20

28

46

–

52

Uganda

284

191

471

74

1.21

38

51

34

45

15

20

64

–

49

Ukraine

17

13

22

100

–

54

68

45

56

6

9

75

95

76

United Arab Emirates

9

5

17

99

–

38

53

31

42

12

16

62

–

82

United Kingdom of Great Britain andNorthern Ireland

10

8

12

–

–

72

76

65

69

4

6

86

96

88

United Republic of Tanzania

238

174

381

64

0.54

38

47

34

42

15

19

64

–

43

United States of America

21

16

27

99

–

61

76

54

67

5

5

81

–

86

United States Virgin Islands

–

–

–

–

–

45

75

42

70

8

8

79

–

–

Uruguay

19

15

23

100

0.24

59

79

57

77

6

7

87

97

82

Uzbekistan

30

23

40

99

–

49

70

46

66

6

8

84

92

75

Vanuatu

94

43

211

89

–

38

49

33

42

15

19

62

–

47

Venezuela (Bolivarian Republic of)

259

191

381

99

–

56

76

53

72

8

9

83

–

75

Viet Nam

46

33

60

96

0.06

58

79

48

66

4

5

78

54

68

Western Sahara

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Yemen

183

120

271

45

0.03

29

46

21

34

14

22

51

65

42

Zambia

135

100

201

80

1.86

38

54

37

52

15

17

70

91

56

Zimbabwe

357

255

456

86

1.12

51

70

50

69

8

9

86

73

55

138

Indicators

swp2024-english-240327.indd 138

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Sexual and reproductive health
NOTES

MAIN DATA SOURCES– Data not available.

Maternal mortality ratio: United Nations Maternal Mortality Estimation
Inter-agency Group (WHO, UNICEF, UNFPA, The World Bank and United
Nations Population Division), 2023.

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

DEFINITIONS OF THE INDICATORS

Births attended by skilled health personnel: Joint global database on skilledattendance at birth. UNICEF and WHO, 2023. Regional aggregates calculated
by UNFPA based on data from the joint global database.
Number of new HIV infections, all ages, per 1,000 uninfected population:
HIV Estimates. UNAIDS, 2023.

Maternal mortality ratio: Number of maternal deaths during a given
time period per 100,000 live births during the same time period (SDG
indicator 3.1.1).

Contraceptive prevalence rate: United Nations Population Division, 2022.

Births attended by skilled health personnel: Percentage of births attended
by skilled health personnel (doctor, nurse or midwife) (SDG indicator 3.1.2).

Unmet need for family planning: United Nations Population Division, 2022.

Number of new HIV infections, all ages, per 1,000 uninfected population:
Number of new HIV infections per 1,000 person-years among the uninfected
population (SDG indicator 3.3.1).
Contraceptive prevalence rate: Percentage of women aged 15 to 49 years
who are currently using any method of contraception.

Contraceptive prevalence rate, modern method: United Nations Population
Division, 2022.
Proportion of demand satisﬁed with modern methods: United Nations
Population Division, 2022.
Laws and regulations that guarantee access to sexual and reproductive
health care, information and education: UNFPA, 2022.
Universal health coverage (UHC) service coverage index: WHO, 2023.

Contraceptive prevalence rate, modern method: Percentage of women aged
15 to 49 years who are currently using any modern method of contraception.
Unmet need for family planning: Percentage of women aged 15 to49 years who want to stop or delay childbearing but are not using a methodof contraception.
Proportion of demand satisﬁed with modern methods: Percentage of
total demand for family planning among women aged 15 to 49 years that is
satisﬁed by the use of modern contraception (SDG indicator 3.7.1).
Laws and regulations that guarantee access to sexual and reproductive
health care, information and education: The extent to which countries havenational laws and regulations that guarantee full and equal access to womenand men aged 15 years and older to sexual and reproductive health care,information and education (SDG indicator 5.6.2).
Universal health coverage (UHC) service coverage index: Average coverageof essential services based on tracer interventions that include reproductive,
maternal, newborn and child health, infectious diseases, non-communicablediseases and service capacity and access, among the general and the mostdisadvantaged population (SDG indicator 3.8.1).

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Gender, rights and human capitalCountries,
other areasWorld
andterritories,
regional areas

AdolescentChild
Female genital
Intimate
Decision-making
DecisionDecisionDecisionbirth rate
marriagemutilation
partneron sexual andmaking on
making on
makingper 1,000 by age 18,
prevalence violence, past reproductive
women’s own contraceptive on sexual
girls aged
per cent among women 12 months,
health andhealth care, use, per cent intercourse,
15–19
aged 15–49,
per cent
reproductive
per cent
per cent
per centrights, per centTotal net Gender parity Total net Gender parity
enrolment
index, total
enrolment
index, total
rate, lower net enrolment rate, upper net enrolment
secondaryrate, lower
secondaryrate, upper
education,
secondaryeducation,
secondary
per cent
education
per cent
education

2023
2006–2023
2024
2000–2023

2022
2004–2022

2018

2007–2022

2007–2022

2007–2022

2007–2022

2020
2017–2023

2020
2017–2023

2020
2017–2023

2020
2017–2023

World

41

19

–

13

56

75

89

76

85

1.00

67

1.01

More developed regions

10

4

–

–

82

97

95

87

99

1.00

95

1.01

Less developed regions

45

22

–

–

56

75

89

75

83

1.00

63

1.01

Least developed countries

90

38

–

22

47

68

88

69

–

–

44

0.90

UNFPA regions
Arab States

42

17

54

15

58

92

91

67

82

0.95

60

0.92

Asia and the Paciﬁc

24

18

–

13

63

79

91

81

87

1.02

66

1.06

Eastern Europe and Central Asia

18

10

–

9

70

89

91

81

98

1.00

84

0.99

Latin America and the Caribbean

51

21

–

8

72

86

91

90

94

1.02

79

1.03

East and Southern Africa

92

30

–

24

48

76

88

67

–

–

–

–

West and Central Africa

101

33

18

15

26

44

80

55

61

0.97

41

0.87

Countries, territories, other areas

2004–2022

2018

2007–2022

2007–2022

2007–2022

2007–2022

2017–2023

2017–2023

2017–2023

2017–2023

Afghanistan

2000–2023 2006–2023
62

29

–

35

–

–

–

–

–

–

45

0.56

Albania

12

12

–

6

62

92

83

77

96

0.94

85

0.96

Algeria

11

4

–

–

–

–

–

–

97

0.99

83

1.11

Angola

163

30

–

25

39

75

74

62

–

–

–

–

Antigua and Barbuda

33

–

–

–

–

–

–

–

100

–

95

0.99

Argentina

28

16

–

5

–

–

–

–

99

–

96

1.10

Armenia

13

5

–

5

62

96

83

75

100

0.99

97

1.06

Aruba

13

–

–

–

–

–

–

–

–

–

–

–

Australia

7

–

–

3

–

–

–

–

98

1.01

94

1.05

Austria

4

–

–

4

–

–

–

–

98

1.00

89

1.00

Azerbaijan

37

11

–

5

–

–

–

–

87

0.99

80

0.96

Bahamas

26

–

–

–

–

–

–

–

86

0.99

63

1.01

Bahrain

9

–

–

–

87

93

92

79

97

1.00

98

0.98

Bangladesh

68

51

–

23

64

77

94

86

82

1.15

79

0.91

Barbados

48

29

–

–

–

–

–

–

99

1.00

93

1.01

Belarus

12

5

–

6

–

–

–

–

94

0.97

88

1.01

Belgium

4

0

–

5

–

–

–

–

99

1.00

99

1.00

Belize

51

34

–

8

–

–

–

–

94

0.99

71

1.11

Benin

84

28

9

15

32

52

66

58

55

0.91

31

0.78

Bhutan

10

26

–

9

–

–

–

–

85

1.15

67

1.15

Bolivia (Plurinational State of)

71

20

–

18

–

–

–

–

89

1.01

80

1.01
1.03

Bosnia and Herzegovina

10

4

–

3

–

–

–

–

94

0.97

79

Botswana

50

–

–

17

–

–

–

–

86

1.08

57

0.98

Brazil

43

26

–

7

–

–

–

–

96

1.01

89

1.05

Brunei Darussalam

9

–

–

–

–

–

–

–

99

1.01

68

1.06

Bulgaria

39

–

–

6

–

–

–

–

90

1.00

82

0.95

Burkina Faso

93

51

56

11

20

32

91

62

46

1.14

27

1.16

Burundi

58

19

–

22

40

72

88

60

59

1.06

42

1.17

Cabo Verde

40

8

–

11

–

–

–

–

83

0.99

74

1.07

Cambodia

48

18

–

9

80

92

93

91

95

1.09

57

1.12

Cameroon

105

30

1

22

35

55

74

67

53

0.93

35

0.86

140

Indicators

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Gender, rights and human capitalCountries, territories, other areas
CanadaAdolescentChild
Female genital
Intimate
Decision-making
DecisionDecisionDecisionbirth rate
marriagemutilation
partneron sexual andmaking on
making on
makingper 1,000 by age 18,
prevalence violence, past reproductive
women’s own contraceptive on sexual
girls aged
per cent among women 12 months,
health andhealth care, use, per cent intercourse,
15–19
aged 15–49,
per cent
reproductive
per cent
per cent
per centrights, per centTotal net Gender parity Total net Gender parity
enrolment
index, total
enrolment
index, total
rate, lower net enrolment rate, upper net enrolment
secondaryrate, lower
secondaryrate, upper
education,
secondaryeducation,
secondary
per cent
education
per cent
education

2000–2023 2006–2023

2004–2022

2018

2007–2022

2007–2022

2007–2022

2007–2022

2017–2023

2017–2023

2017–2023

2017–2023

5

–

–

3

–

–

–

–

100

–

87

0.98

Central African Republic

184

61

22

21

–

–

–

–

43

0.68

17

0.60

Chad

138

61

34

16

27

47

81

63

41

0.72

25

0.57

Chile

16

–

–

6

–

–

–

–

99

0.99

98

0.99

China

6

3

–

8

–

–

–

–

–

–

–

–

China, Hong Kong Special
Administrative Region

1

–

–

3

–

–

–

–

99

0.97

94

0.99

China, Macao Special
Administrative Region

0

–

–

–

–

–

–

–

90

0.97

82

1.06

Colombia

47

23

–

12

–

–

–

–

96

1.01

87

1.03

Comoros

74

21

–

8

21

47

71

47

87

1.02

52

1.07

Congo

111

27

–

–

27

41

87

71

70

0.94

58

0.92

Costa Rica

26

17

–

7

–

–

–

–

95

1.01

92

1.03

Côte d'Ivoire

96

26

37

16

25

43

82

67

43

1.01

45

0.92

Croatia

7

–

–

4

–

–

–

–

99

–

92

1.05
1.05

Cuba

47

29

–

5

–

–

–

–

92

1.00

83

Curaçao

18

–

–

–

–

–

–

–

99

–

88

1.02

Cyprus

6

–

–

3

–

–

–

–

100

–

96

1.00

Czechia

7

–

–

4

–

–

–

–

98

1.00

95

1.01

Democratic People's Republicof Korea

1

0

–

–

–

–

–

–

–

–

–

–

109

29

–

36

31

47

85

74

–

–

–

–

Denmark

Democratic Republic of the Congo

1

1

–

3

–

–

–

–

99

1.00

93

1.01

Djibouti

21

7

90

–

–

–

–

–

49

0.86

36

0.91

Dominica

50

–

–

–

–

–

–

–

81

0.95

77

0.92

Dominican Republic

77

32

–

10

77

88

92

93

89

1.01

68

1.09

Ecuador

52

22

–

8

87

100

92

95

99

1.02

80

1.02

Egypt

50

16

87

15

–

–

–

–

95

1.00

72

0.95
1.07

El Salvador

50

20

–

6

–

–

–

–

–

–

57

Equatorial Guinea

176

30

–

29

–

–

–

–

–

–

–

–

Eritrea

76

41

83

–

–

–

–

–

59

0.86

45

0.86
1.01

Estonia

6

–

–

4

–

–

–

–

98

1.00

94

Eswatini

87

2

–

18

49

72

89

74

–

–

–

–

Ethiopia

72

40

65

27

38

82

90

46

50

0.99

33

0.96

Fiji

31

4

–

23

62

86

84

77

89

0.81

73

1.13

Finland

3

0

–

8

–

–

–

–

98

1.00

96

1.01

France

6

–

–

5

–

–

–

–

100

1.00

96

1.01

French Guiana

58

–

–

–

–

–

–

–

–

–

–

–

French Polynesia

23

–

–

–

–

–

–

–

–

–

–

–

Gabon

100

13

–

22

48

60

90

86

64

1.03

53

1.05

Gambia

65

23

73

10

19

49

87

45

80

1.18

55

1.25

Georgia

22

14

–

3

82

95

98

88

99

–

99

1.01
0.98

Germany

6

–

–

–

–

–

–

–

99

1.01

89

Ghana

63

16

2

10

52

82

90

72

91

0.99

66

0.94

Greece

7

–

–

5

–

–

–

–

98

1.00

94

1.02

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Gender, rights and human capitalCountries, territories, other areas

AdolescentChild
Female genital
Intimate
Decision-making
DecisionDecisionDecisionbirth rate
marriagemutilation
partneron sexual andmaking on
making on
makingper 1,000 by age 18,
prevalence violence, past reproductive
women’s own contraceptive on sexual
girls aged
per cent among women 12 months,
health andhealth care, use, per cent intercourse,
15–19
aged 15–49,
per cent
reproductive
per cent
per cent
per centrights, per centTotal net Gender parity Total net Gender parity
enrolment
index, total
enrolment
index, total
rate, lower net enrolment rate, upper net enrolment
secondaryrate, lower
secondaryrate, upper
education,
secondaryeducation,
secondary
per cent
education
per cent
education

2000–2023 2006–2023

2007–2022

2017–2023

2017–2023

2017–2023

2017–2023

2004–2022

2018

2007–2022

2007–2022

2007–2022

Grenada

30

–

–

8

–

–

–

–

91

1.07

86

0.96

Guadeloupe

8

–

–

–

–

–

–

–

–

–

–

–

Guam

35

–

–

–

–

–

–

–

–

–

–

–

Guatemala

65

30

–

7

65

77

91

89

63

0.95

35

1.04
0.67

Guinea

128

47

95

21

15

41

76

40

47

0.78

27

Guinea-Bissau

84

26

52

–

–

–

–

–

–

–

–

–

Guyana

65

32

–

11

71

92

90

83

83

1.04

62

1.09

Haiti

55

15

–

12

57

76

93

79

–

–

–

–

Honduras

97

34

–

7

70

84

88

94

53

1.10

39

1.18

Hungary

19

–

–

6

–

–

–

–

95

1.00

87

1.01

Iceland

3

–

–

3

–

–

–

–

99

1.00

85

1.01

India

11

23

–

18

66

82

92

83

85

1.01

57

1.01

Indonesia

36

16

–

9

–

–

–

–

95

1.07

82

0.95

Iran (Islamic Republic of)

24

17

–

18

–

–

–

–

95

0.97

81

0.98

Iraq

70

28

7

–

–

–

–

–

–

–

–

–

Ireland

4

–

–

3

–

–

–

–

100

–

99

1.02

Israel

7

–

–

6

–

–

–

–

97

1.00

95

1.02

Italy

3

–

–

4

–

–

–

–

99

1.00

95

1.00

Jamaica

36

8

–

7

–

–

–

–

82

1.04

77

0.98
1.02

Japan

2

–

–

4

–

–

–

–

100

–

98

Jordan

17

10

–

14

58

92

91

67

74

0.98

62

1.05

Kazakhstan

20

7

–

6

–

–

–

–

98

1.00

70

1.08

Kenya

44

13

15

23

65

87

92

77

–

–

–

–

Kiribati

51

18

–

25

–

–

–

–

–

–

–

–

Kuwait

2

–

–

–

–

–

–

–

–

–

–

–

Kyrgyzstan

30

13

–

13

77

94

95

85

94

0.98

73

1.04

Lao People's Democratic Republic

83

33

–

8

–

–

–

–

66

1.01

46

0.93

Latvia

9

–

–

6

–

–

–

–

99

1.01

94

1.02

Lebanon

17

6

–

–

–

–

–

–

–

–

–

–

Lesotho

49

16

–

17

61

90

93

71

83

1.08

63

1.11

Liberia

131

25

32

27

59

79

84

82

60

1.02

61

1.03

Libya

11

–

–

–

–

–

–

–

–

–

–

–

Lithuania

6

0

–

5

–

–

–

–

100

–

99

1.02

Luxembourg

3

–

–

4

–

–

–

–

96

1.00

85

1.05

Madagascar

143

39

–

–

72

87

93

88

65

1.02

31

1.00

Malawi

136

38

–

17

45

68

91

69

76

0.99

30

0.62

Malaysia

6

–

–

–

–

–

–

–

89

1.03

67

1.10
1.14

Maldives

5

2

13

6

54

89

84

70

96

1.06

55

Mali

145

54

89

18

5

20

66

26

45

0.86

24

0.74

Malta

10

–

–

4

–

–

–

–

98

0.99

90

1.02

Martinique

9

–

–

–

–

–

–

–

–

–

–

–

Mauritania

90

37

64

–

25

63

79

44

67

1.04

38

1.04

Mauritius

20

–

–

–

–

–

–

–

95

1.01

77

1.10

Mexico

44

21

–

10

–

–

–

–

92

1.03

69

1.11

142

Indicators

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Gender, rights and human capitalCountries, territories, other areas

AdolescentChild
Female genital
Intimate
Decision-making
DecisionDecisionDecisionbirth rate
marriagemutilation
partneron sexual andmaking on
making on
makingper 1,000 by age 18,
prevalence violence, past reproductive
women’s own contraceptive on sexual
girls aged
per cent among women 12 months,
health andhealth care, use, per cent intercourse,
15–19
aged 15–49,
per cent
reproductive
per cent
per cent
per centrights, per centTotal net Gender parity Total net Gender parity
enrolment
index, total
enrolment
index, total
rate, lower net enrolment rate, upper net enrolment
secondaryrate, lower
secondaryrate, upper
education,
secondaryeducation,
secondary
per cent
education
per cent
education

2000–2023 2006–2023

2017–2023

2017–2023

2017–2023

2017–2023
1.08

2004–2022

2018

2007–2022

2007–2022

2007–2022

2007–2022

Micronesia (Federated States of)

33

–

–

21

–

–

–

–

83

1.03

62

Mongolia

21

12

–

12

63

85

84

80

96

1.02

88

1.07

Montenegro

9

6

–

4

–

–

–

–

98

0.98

87

1.02

Morocco

22

14

–

11

–

–

–

–

96

0.97

77

0.99

Mozambique

158

53

–

16

49

77

85

67

59

0.93

42

0.88

Myanmar

36

16

–

11

67

85

98

81

88

1.07

63

1.17

Namibia

64

7

–

16

71

91

83

93

100

1.00

88

0.95

Nepal

71

35

–

11

63

72

91

91

96

0.94

81

1.03

Netherlands

2

–

–

5

–

–

–

–

100

1.00

95

1.02

New Caledonia

11

–

–

–

–

–

–

–

–

–

–

–

New Zealand

11

–

–

4

–

–

–

–

98

1.00

95

1.01

Nicaragua

79

35

–

6

–

–

–

–

–

–

–

–

Niger

150

76

2

13

7

21

77

35

25

0.96

10

0.85

Nigeria

75

30

15

13

29

46

81

56

–

–

–

–

North Macedonia

14

8

–

4

88

98

99

90

–

–

–

–

Norway

1

0

–

4

–

–

–

–

100

1.00

95

1.01

Oman

6

4

–

–

–

–

–

–

86

1.01

76

0.99

Pakistan

41

18

–

16

31

52

85

55

72

0.82

51

0.84

Panama

62

26

–

8

79

94

89

95

88

1.02

57

1.08

Papua New Guinea

68

27

–

31

57

86

84

76

69

0.93

43

0.83

Paraguay

72

22

–

6

–

–

–

–

82

1.01

73

1.06

Peru

34

14

–

11

–

–

–

–

98

1.00

84

0.99

Philippines

47

9

–

6

82

95

91

92

89

1.05

82

1.10

Poland

6

–

–

3

–

–

–

–

97

1.00

96

1.01

Portugal

6

–

–

4

–

–

–

–

100

1.00

100

1.00

Puerto Rico

13

–

–

–

–

–

–

–

94

1.04

86

0.98

Qatar

5

4

–

–

–

–

–

–

98

1.00

90

0.99

Republic of Korea

0

–

–

8

–

–

–

–

100

1.00

96

0.99

Republic of Moldova

27

12

–

9

73

96

96

79

100

–

85

1.04

Réunion

15

–

–

–

–

–

–

–

–

–

–

–

Romania

34

7

–

7

–

–

–

–

89

0.99

77

1.02

Russian Federation

13

6

–

–

–

–

–

–

100

1.00

57

0.95

Rwanda

31

6

–

24

61

83

95

76

91

1.06

56

1.06

Saint Kitts and Nevis

74

–

–

–

–

–

–

–

–

–

95

–

Saint Lucia

24

24

–

–

–

–

–

–

87

1.09

76

1.02

Saint Vincent and the Grenadines

37

–

–

–

–

–

–

–

98

–

97

1.02

Samoa

55

7

–

18

–

–

–

–

100

1.00

77

1.15
0.81

San Marino

1

–

–

–

–

–

–

–

94

0.99

40

Sao Tome and Principe

86

28

–

18

46

69

78

79

–

–

–

–

Saudi Arabia

8

–

–

–

–

–

–

–

99

1.00

99

1.00

Senegal

67

31

25

12

6

27

81

18

38

1.18

19

1.20

Serbia

13

6

–

4

96

100

98

98

95

1.00

84

1.05

Seychelles

46

–

–

–

–

–

–

–

96

1.03

87

1.14

Sierra Leone

102

30

83

20

28

44

78

68

82

1.05

58

1.01

S TAT E O F W O R L D P O P U L AT I O N 2024

143

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Gender, rights and human capitalCountries, territories, other areas

AdolescentChild
Female genital
Intimate
Decision-making
DecisionDecisionDecisionbirth rate
marriagemutilation
partneron sexual andmaking on
making on
makingper 1,000 by age 18,
prevalence violence, past reproductive
women’s own contraceptive on sexual
girls aged
per cent among women 12 months,
health andhealth care, use, per cent intercourse,
15–19
aged 15–49,
per cent
reproductive
per cent
per cent
per centrights, per centTotal net Gender parity Total net Gender parity
enrolment
index, total
enrolment
index, total
rate, lower net enrolment rate, upper net enrolment
secondaryrate, lower
secondaryrate, upper
education,
secondaryeducation,
secondary
per cent
education
per cent
education

2000–2023 2006–2023

2004–2022

2018

2007–2022

2007–2022

2007–2022

2007–2022

2017–2023

2017–2023

2017–2023

2017–2023
1.00

Singapore

3

0

–

2

–

–

–

–

100

1.00

99

Sint Maarten (Dutch part)

–

–

–

–

–

–

–

–

–

–

–

–

Slovakia

26

–

–

6

–

–

–

–

97

1.00

91

1.00
1.01

Slovenia

3

–

–

3

–

–

–

–

99

1.00

97

Solomon Islands

78

21

–

28

–

–

–

–

–

–

–

–

Somalia

116

45

99

–

–

–

–

–

–

–

–

–

South Africa

71

4

–

13

61

94

85

72

92

1.01

91

1.11

South Sudan

158

52

–

27

–

–

–

–

–

–

–

–

Spain

5

–

–

3

–

–

–

–

97

1.01

95

1.02
1.08

Sri Lanka

17

10

–

4

–

–

–

–

97

1.01

86

State of Palestine1

43

13

–

19

–

–

–

–

95

1.02

76

1.16

Sudan

87

34

87

17

–

–

–

–

70

0.96

51

1.07

Suriname

46

36

–

8

–

–

–

–

–

–

–

–

Sweden

2

–

–

6

–

–

–

–

100

1.00

97

1.00

Switzerland

1

–

–

2

–

–

–

–

100

1.00

92

0.99

Syrian Arab Republic

54

13

–

–

–

–

–

–

48

1.08

27

1.17

Tajikistan

42

9

–

14

27

47

79

54

–

–

–

–

Thailand

24

17

–

9

–

–

–

–

98

1.01

98

1.10

Timor-Leste

42

15

–

28

36

93

92

40

87

1.09

74

1.10

Togo

79

25

3

13

30

47

84

75

82

0.95

46

0.77

Tonga

30

10

–

17

–

–

–

–

99

1.08

82

1.19

Trinidad and Tobago

36

4

–

8

–

–

–

–

–

–

67

0.99

Tunisia

4

2

–

10

–

–

–

–

–

–

–

–

Türkiye

12

15

–

12

–

–

–

–

100

1.00

92

1.00

Turkmenistan

22

6

–

–

59

85

90

70

99

1.01

83

1.00

Turks and Caicos Islands

18

23

–

–

–

–

–

–

87

0.86

85

0.76

Tuvalu

44

2

–

20

–

–

–

–

93

1.06

56

1.25

Uganda

111

34

0

26

58

74

88

86

51

0.98

25

0.83

Ukraine

13

9

–

9

81

98

95

86

89

1.01

78

1.07

United Arab Emirates

3

–

–

–

–

–

–

–

–

–

73

1.36

United Kingdom of Great Britain
and Northern Ireland

8

0

–

4

–

–

–

–

97

1.00

95

1.02

United Republic of Tanzania

112

29

8

24

50

74

85

68

49

1.07

16

0.86

United States of America

14

–

–

6

–

–

–

–

99

1.01

95

1.03

United States Virgin Islands

25

–

–

–

–

–

–

–

–

–

–

–

Uruguay

27

25

–

4

–

–

–

–

97

1.02

90

1.06

Uzbekistan

36

3

–

–

70

89

90

85

100

1.00

73

1.01

Vanuatu

81

21

–

29

–

–

–

–

95

0.95

75

1.06

Venezuela (Bolivarian Republic of)

76

–

–

9

–

–

–

–

83

1.03

72

1.12

Viet Nam

29

15

–

10

–

–

–

–

98

1.02

95

0.93

Western Sahara

–

–

–

–

–

–

–

–

–

–

–

–

Yemen

77

30

19

–

–

–

–

–

–

–

–

–

Zambia

135

29

–

28

47

81

87

64

–

–

–

–

Zimbabwe

87

34

–

18

60

87

93

72

77

–

37

–

144

Indicators

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Gender, rights and human capital
NOTES

MAIN DATA SOURCES– Data not available.

Adolescent birth rate: United Nations Population Division, 2024. Regional
aggregates are from World Population Prospects 2022. United Nations
Population Division, 2022.

¹ On 29 November 2012, the United Nations General Assembly passed
Resolution 67/19, which accorded Palestine “non-member observer Statestatus in the United Nations...”DEFINITIONS OF THE INDICATORS
Adolescent birth rate: Number of births per 1,000 adolescent girls aged
15 to 19 (SDG indicator 3.7.2).
Child marriage by age 18: Proportion of women aged 20 to 24 years who
were married or in a union before age 18 (SDG indicator 5.3.1).
Female genital mutilation prevalence among women aged 15–49:
Proportion of women aged 15 to 49 years who have undergone female
genital mutilation (SDG indicator 5.3.2).
Intimate partner violence, past 12 months: Percentage of ever-partnered
women and girls aged 15 to 49 years who have experienced physical and/or sexual partner violence in the previous 12 months (SDG indicator 5.2.1).
Decision-making on sexual and reproductive health and reproductive
rights: Percentage of women aged 15 to 49 years who are married (orin a union), who make their own decisions on three areas – their healthcare, use of contraception, and sexual intercourse with their partners (SDG
indicator 5.6.1).
Decision-making on women's own health care: Percentage of women
aged 15 to 49 years who are married (or in a union), who make their own
decisions on their health care (SDG indicator 5.6.1).
Decision-making on contraceptive use: Percentage of women aged 15 to49 years who are married (or in a union), who make their own decisions on
use of contraception (SDG indicator 5.6.1).

Child marriage by age 18: UNICEF, 2024. Regional aggregates calculated
by UNFPA based on data from UNICEF.
Female genital mutilation prevalence among women aged 15–49: UNICEF,
2024. Regional aggregates calculated by UNFPA based on data from
UNICEF.
Intimate partner violence, past 12 months: Violence Against Women InterAgency Group on Estimation and Data (WHO, UN Women, UNICEF, United
Nations Statistics Division, United Nations Ofﬁce on Drugs and Crime, andUNFPA), 2021.
Decision-making on sexual and reproductive health and reproductive
rights: UNFPA, 2024.
Decision-making on women's own health care: UNFPA, 2024.
Decision-making on contraceptive use: UNFPA, 2024.
Decision-making on sexual intercourse: UNFPA, 2024.
Total net enrolment rate, lower secondary education: UNESCO Institute for
Statistics, 2024.
Gender parity index, total net enrolment rate, lower secondary education:
UNESCO Institute for Statistics, 2024.
Total net enrolment rate, upper secondary education: UNESCO Institute for
Statistics, 2024.
Gender parity index, total net enrolment rate, upper secondary education:
UNESCO Institute for Statistics, 2024.

Decision-making on sexual intercourse: Percentage of women aged 15 to49 years who are married (or in a union), who make their own decisions on
sexual intercourse with their partners (SDG indicator 5.6.1).
Total net enrolment rate, lower secondary education: Total number ofstudents of the ofﬁcial age group for lower secondary education whoare enrolled in any level of education, expressed as a percentage of thecorresponding population.
Gender parity index, total net enrolment rate, lower secondary education:
Ratio of female to male values of total net enrolment rate for lower
secondary education.
Total net enrolment rate, upper secondary education: Total number ofstudents of the ofﬁcial age group for upper secondary education whoare enrolled in any level of education, expressed as a percentage of thecorresponding population.
Gender parity index, total net enrolment rate, upper secondary education:
Ratio of female to male values of total net enrolment rate for upper
secondary education.

S TAT E O F W O R L D P O P U L AT I O N 2024

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Demographic indicators
POPULATIONPOPULATIONCHANGEPOPULATION COMPOSITIONFERTILITY

LIFE EXPECTANCY

Total population,
millions

Population
annual doubling
time, years

Population
aged 0–14,
per cent

Population
aged 10–19,
per cent

Population
aged 10–24,
per cent

Population
aged 15–64,
per cent

Population
aged 65
and older,
per cent

Total
fertility rate,
per woman

Life expectancy
at birth, years,
2024

World andterritories,
regional areas
Countries,
other areas

2024

2024

2024

2024

2024

World

8,119

77

25

16

24

2024

2024

2024

male

female

65

10

2.3

71

More developed regions

1,277

–

16

11

76

17

64

21

1.5

78

Less developed regions

6,842

66

26

83

17

25

65

8

2.4

70

75

Least developed countries

1,178

31

38

22

31

58

4

3.8

64

69

476

39

32

20

28

63

5

3.0

70

75

UNFPA regions
Arab States
Asia and the Paciﬁc

4,204

108

22

16

23

68

10

1.9

72

77

Eastern Europe and Central Asia

250

71

23

15

21

66

11

2.1

72

79

Latin America and the Caribbean

666

94

23

16

24

68

10

1.8

73

79

East and Southern Africa

688

28

40

23

32

56

3

4.1

62

67

West and Central Africa

516

28

42

23

33

55

3

4.8

57

59

Countries, territories, other areas

2024

2024

2024

2024

2024

2024

2024

2024

male

femaleAfghanistan

43.4

26

43

24

34

55

2

4.3

62

68

Albania

2.8

–

16

12

18

66

18

1.4

78

82

Algeria

46.3

49

30

17

24

63

7

2.7

76

79

Angola

37.8

23

45

24

32

53

3

5.0

61

66

Antigua and Barbuda

0.1

127

18

13

20

71

12

1.6

77

82

Argentina

46.1

113

22

16

23

65

12

1.9

75

81

Armenia

2.8

–

20

13

19

65

14

1.6

71

80

Aruba1

0.1

–

15

13

19

67

18

1.2

74

80

Australia2

26.7

71

18

12

18

65

18

1.6

82

86

Austria

9.0

–

14

10

15

65

21

1.5

81

85

Azerbaijan3

10.5

–

22

16

22

70

8

1.6

71

77

Bahamas

0.4

111

18

14

23

72

10

1.4

71

78

Bahrain

1.5

79

20

13

18

76

4

1.8

80

82

Bangladesh

174.7

70

25

18

27

68

6

1.9

72

77

Barbados

0.3

–

16

12

19

66

17

1.6

76

80

Belarus

9.5

–

16

12

17

65

18

1.5

70

80

Belgium

11.7

–

16

12

17

63

20

1.6

81

85

Belize

0.4

50

27

18

28

68

5

2.0

72

78

Benin

14.1

26

42

23

31

55

3

4.7

60

63

Bhutan

0.8

111

21

17

26

73

7

1.4

71

75

Bolivia (Plurinational State of)

12.6

49

30

20

29

65

5

2.5

66

72

Bosnia and Herzegovina

3.2

–

15

10

16

66

19

1.3

76

80

Botswana

2.7

43

32

20

28

64

4

2.7

64

69

Brazil

217.6

127

20

14

21

70

11

1.6

73

79

Brunei Darussalam

0.5

97

21

15

22

72

7

1.7

73

77

Bulgaria

6.6

–

14

10

15

64

22

1.6

73

79

Burkina Faso

23.8

28

43

24

34

55

3

4.5

59

63

Burundi

13.6

26

44

26

34

53

3

4.8

61

65

Cabo Verde

0.6

72

25

18

26

69

6

1.9

73

81

Cambodia

17.1

68

28

19

27

65

6

2.3

69

74

Cameroon

29.4

27

42

23

32

56

3

4.2

61

64

146

Indicators

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Demographic indicators
POPULATIONPOPULATIONCHANGEPOPULATION COMPOSITION

Total population,
millions

Population
annual doubling
time, years

Population
aged 0–14,
per cent

Population
aged 10–19,
per cent

Population
aged 10–24,
per cent

Population
aged 15–64,
per cent

FERTILITY

LIFE EXPECTANCY

Population
aged 65
and older,
per cent

Total
fertility rate,
per woman

Life expectancy
at birth, years,
2024

Countries, territories, other areas

2024

2024

2024

2024

2024

2024

2024

2024

male

femaleCanada

39.1

84

15

11

17

65

20

1.5

81

85

Central African Republic

5.9

23

48

26

37

50

3

5.7

54

58

Chad

18.8

23

47

24

33

51

2

6.0

52

56

Chile

19.7

–

18

12

19

68

14

1.5

79

84

China4

1,425.2

–

16

12

18

69

15

1.2

76

82

China, Hong Kong Special
Administrative Region5

7.5

–

12

8

12

66

22

0.8

83

89

China, Macao Special
Administrative Region6

0.7

55

15

8

13

71

14

1.2

83

88

Colombia

52.3

–

21

14

22

69

10

1.7

75

81

Comoros

0.9

39

37

21

30

58

4

3.8

63

68

Congo

6.2

31

40

24

32

57

3

4.0

62

65

Costa Rica

5.2

107

19

14

21

69

12

1.5

78

83

Côte d'Ivoire

29.6

28

41

24

33

57

2

4.2

59

62

Croatia

4.0

–

14

10

15

63

23

1.4

77

82

Cuba

11.2

–

15

11

17

68

16

1.5

76

81

Curaçao1

0.2

–

17

12

20

67

16

1.6

73

81

Cyprus7

1.3

107

16

10

16

69

16

1.3

80

84

Czechia

10.5

–

16

11

16

64

21

1.7

77

83

Democratic People's Republic of Korea

26.2

–

19

12

19

69

13

1.8

71

76

Democratic Republic of the Congo

105.6

21

46

23

32

51

3

6.0

59

63

Denmark

5.9

–

16

11

17

63

21

1.7

80

84

Djibouti

1.2

50

30

19

29

66

5

2.7

62

67

Dominica

0.1

–

19

14

22

71

10

1.6

71

78

Dominican Republic

11.4

79

27

17

26

66

8

2.2

71

78

Ecuador

18.4

68

25

17

26

67

8

2.0

76

81

Egypt

114.5

44

32

20

28

63

5

2.8

70

75

El Salvador

6.4

–

25

17

27

67

9

1.8

69

78

Equatorial Guinea

1.8

30

38

22

29

59

3

4.0

61

64

Eritrea

3.8

37

38

25

35

58

4

3.6

67

71

Estonia

1.3

–

16

11

16

63

21

1.7

75

83

Eswatini

1.2

67

34

22

31

62

4

2.7

58

65

Ethiopia

129.7

28

39

23

32

58

3

3.9

64

70

0.9

97

28

18

26

66

6

2.4

67

71

Finland9

5.5

–

15

11

17

61

24

1.4

80

85

France10

64.9

–

17

12

18

61

22

1.8

81

86

French Guiana

0.3

29

32

18

27

62

6

3.4

75

81

French Polynesia11

0.3

88

20

15

22

69

11

1.7

82

86

Gabon

2.5

36

36

21

29

60

4

3.3

65

70

Gambia

2.8

29

42

24

34

55

2

4.4

63

66

Georgia12

3.7

–

21

13

19

64

15

2.0

69

79

Germany

83.3

–

14

9

14

63

23

1.5

80

85

Ghana

34.8

36

36

22

31

60

4

3.4

63

68

Greece

10.3

–

13

10

16

63

24

1.4

80

85

Grenada

0.1

129

24

15

22

66

11

2.0

73

79

8

Fiji

11

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Demographic indicators
POPULATIONPOPULATIONCHANGEFERTILITY

LIFE EXPECTANCY

Total population,
millions

Population
annual doubling
time, years

Population
aged 0–14,
per cent

Population
aged 10–19,
per cent

Population
aged 10–24,
per cent

Population
aged 15–64,
per cent

Population
aged 65
and older,
per cent

Total
fertility rate,
per woman

Life expectancy
at birth, years,
2024

Countries, territories, other areas

2024

2024

2024

2024

2024

Guadeloupe11

0.4

–

18

13

20

2024

2024

2024

male

female

61

21

2.0

80

Guam13

0.2

105

26

17

87

25

62

13

2.5

75

Guatemala

18.4

46

31

82

21

31

64

5

2.3

71

77

Guinea14.5

29

Guinea-Bissau

2.2

32

41

23

33

56

3

4.1

59

62

39

24

33

58

3

3.8

60

Guyana

0.8

64

101

28

18

27

65

7

2.3

66

Haiti

73

11.9

58

31

20

29

64

5

2.7

62

68

Honduras

10.8

45

29

19

29

66

5

2.3

71

76

Hungary

10.0

–

14

10

16

65

20

1.6

74

80

Iceland

0.4

111

18

13

19

66

16

1.7

82

85

India

POPULATION COMPOSITION

1,441.7

77

24

17

26

68

7

2.0

71

74

Indonesia

279.8

87

25

17

25

68

7

2.1

69

73

Iran (Islamic Republic of)

89.8

101

23

15

21

69

8

1.7

75

80

Iraq

46.5

32

37

22

32

60

3

3.3

70

74

Ireland

5.1

111

19

14

20

65

16

1.8

81

85

Israel

9.3

47

28

17

24

60

12

2.9

82

85

Italy

58.7

–

12

9

14

63

25

1.3

82

86

Jamaica

2.8

–

19

15

23

73

8

1.3

70

75

Japan

122.6

–

11

9

13

58

30

1.3

82

88

Jordan

11.4

–

31

20

29

65

4

2.7

75

79

Kazakhstan

19.8

60

29

17

23

62

8

3.0

68

76

Kenya

56.2

35

37

23

33

60

3

3.2

62

67

Kiribati

0.1

42

36

21

29

60

4

3.2

66

70

Kuwait

4.3

78

19

14

19

75

6

2.0

79

83

Kyrgyzstan

6.8

46

34

20

27

61

5

2.9

68

76

Lao People's Democratic Republic

7.7

52

30

19

28

65

5

2.4

67

72

Latvia

1.8

–

15

11

15

62

23

1.6

72

80

Lebanon

5.2

–

27

20

27

62

11

2.0

78

82

Lesotho

2.4

64

34

21

30

62

4

2.9

52

58

Liberia

5.5

32

40

24

34

57

3

3.9

61

64

Libya

7.0

65

27

19

28

68

5

2.3

70

77

Lithuania

2.7

–

15

10

15

63

22

1.6

73

81

Luxembourg

0.7

69

16

11

16

69

16

1.4

81

85

Madagascar

31.1

29

38

22

32

58

3

3.7

65

70

Malawi

21.5

27

42

25

35

56

3

3.7

62

69

Malaysia14

34.7

67

22

15

23

70

8

1.8

74

79

Maldives

0.5

–

22

13

19

73

5

1.7

81

82

Mali

24.0

23

47

25

34

51

2

5.7

60

62

Malta

0.5

–

13

8

13

67

20

1.2

82

86
86

Martinique

0.4

–

15

12

18

60

24

1.9

81

Mauritania

5.0

26

41

24

33

56

3

4.2

65

69

Mauritius15

1.3

–

16

12

20

70

14

1.4

73

79

129.4

97

24

17

25

68

9

1.8

72

79

0.1

74

30

20

30

64

7

2.6

68

76

11

MexicoMicronesia (Federated States of)148

Indicators

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Demographic indicators
POPULATIONPOPULATIONCHANGEPOPULATION COMPOSITION

Total population,
millions

Population
annual doubling
time, years

Population
aged 0–14,
per cent

Population
aged 10–19,
per cent

Population
aged 10–24,
per cent

Population
aged 15–64,
per cent

FERTILITY

LIFE EXPECTANCY

Population
aged 65
and older,
per cent

Total
fertility rate,
per woman

Life expectancy
at birth, years,
2024

Countries, territories, other areas

2024

2024

2024

2024

2024

2024

2024

2024

male

femaleMongolia

3.5

53

32

18

25

63

5

2.7

69

78

Montenegro

0.6

–

18

12

18

65

17

1.7

75

81

Morocco

38.2

72

26

17

25

66

8

2.2

73

78

Mozambique

34.9

25

43

24

33

54

3

4.4

60

65

Myanmar

55.0

100

24

16

24

69

7

2.1

65

71

Namibia

2.6

41

36

21

30

60

4

3.2

60

68

Nepal

31.2

64

28

19

29

66

6

2.0

69

73

Netherlands16

17.7

–

15

11

17

64

21

1.6

81

84

New Caledonia11

0.3

70

22

15

22

67

12

2.0

78

85

New Zealand17

5.3

89

18

13

19

65

17

1.7

82

85

Nicaragua

7.1

52

29

19

28

65

6

2.2

72

78

Niger

28.2

18

49

24

33

49

2

6.6

63

65

Nigeria

229.2

29

42

23

33

55

3

5.0

54

55

North Macedonia

2.1

–

16

11

17

69

16

1.4

76

80

Norway18

5.5

95

16

12

18

65

19

1.5

82

85

Oman

4.7

48

27

15

21

70

3

2.5

78

81

Pakistan

245.2

36

36

22

32

60

4

3.3

65

70

Panama

4.5

53

26

17

24

65

9

2.3

76

82

Papua New Guinea

10.5

39

34

21

30

63

3

3.1

64

69

Paraguay

6.9

57

28

18

26

65

7

2.4

71

77

Peru

34.7

73

25

17

25

66

9

2.1

75

79

Philippines

119.1

47

30

19

28

65

6

2.7

70

74

Poland

40.2

–

15

10

16

66

19

1.5

75

82

Portugal

10.2

–

13

10

15

63

24

1.4

80

85

Puerto Rico13

3.3

–

13

10

17

63

24

1.3

76

84

Qatar

2.7

93

15

10

13

83

2

1.8

81

83

Republic of Korea

51.7

–

11

9

14

70

19

0.9

81

87

Republic of Moldova19

3.3

–

19

12

18

67

13

1.8

67

76

Réunion11

1.0

92

22

15

23

64

14

2.2

80

86

Romania

19.6

–

16

11

16

65

19

1.7

74

81

Russian Federation

144.0

–

17

12

17

66

17

1.5

70

79

Rwanda

14.4

31

38

23

32

59

3

3.6

65

70

Saint Kitts and Nevis

0.0

–

19

13

20

70

11

1.5

69

76

Saint Lucia

0.2

–

17

13

20

73

10

1.4

71

78

Saint Vincent and the Grenadines

0.1

–

21

15

22

67

11

1.8

71

77

Samoa

0.2

48

37

22

30

57

5

3.8

70

76

San Marino

0.03

–

12

10

16

67

21

1.2

82

85

Sao Tome and Principe

0.2

36

38

24

34

58

4

3.6

66

72

Saudi Arabia

37.5

50

25

16

23

71

3

2.3

77

80

Senegal

18.2

27

41

23

33

56

3

4.2

67

73

Serbia20

7.1

–

15

10

15

65

21

1.5

74

80

Seychelles

0.1

128

23

14

21

68

9

2.3

72

80

Sierra Leone

9.0

33

38

23

33

59

3

3.7

60

63

Singapore

6.1

112

12

8

13

71

17

1.1

82

87

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Demographic indicators
POPULATIONPOPULATIONCHANGEPOPULATION COMPOSITIONFERTILITY

LIFE EXPECTANCY

Total population,
millions

Population
annual doubling
time, years

Population
aged 0–14,
per cent

Population
aged 10–19,
per cent

Population
aged 10–24,
per cent

Population
aged 15–64,
per cent

Population
aged 65
and older,
per cent

Total
fertility rate,
per woman

Life expectancy
at birth, years,
2024

Countries, territories, other areas

2024

2024

2024

2024

2024

Sint Maarten (Dutch part)1

0.0

–

10

12

24

2024

2024

2024

male

female

77

13

1.6

73

Slovakia

5.7

–

16

10

79

16

67

18

1.6

75

Slovenia

2.1

–

15

82

10

15

63

22

1.6

80

85

Solomon Islands

0.8

32

Somalia

18.7

23

39

22

31

58

4

3.8

69

73

47

24

33

51

3

6.0

56

South Africa

61.0

60

64

28

18

25

66

6

2.3

64

South Sudan

70

11.3

41

42

28

38

55

3

4.1

56

59

Spain21

47.5

–

13

10

16

66

21

1.3

82

87

Sri Lanka

21.9

–

22

16

23

66

12

1.9

73

81

State of Palestine22

5.5

30

38

22

32

58

4

3.3

74

78

Sudan

49.4

27

40

22

31

56

4

4.3

64

69

Suriname

0.6

79

26

17

26

66

8

2.3

70

76

Sweden

10.7

121

17

12

18

62

21

1.7

82

85

Switzerland

8.9

113

15

10

15

65

20

1.5

83

86

Syrian Arab Republic

24.3

15

28

23

35

67

5

2.6

69

76

Tajikistan

10.3

38

36

21

29

60

4

3.1

69

74

Thailand

71.9

–

15

11

17

68

17

1.3

76

84

Timor-Leste

1.4

50

34

22

33

61

5

2.9

68

71

Togo

9.3

31

39

23

32

57

3

4.1

61

63

Tonga

0.1

83

34

22

31

60

6

3.1

69

74

Trinidad and Tobago

1.5

–

18

13

19

69

12

1.6

72

78

Tunisia

12.6

84

24

15

22

66

10

2.0

74

80

Türkiye

86.3

137

23

15

22

68

9

1.9

76

82

Turkmenistan

6.6

57

31

18

26

64

6

2.6

66

73

Turks and Caicos Islands

0.0

87

17

11

16

73

11

1.6

73

79

Tuvalu

0.0

95

32

19

27

61

7

3.1

61

70

Uganda

49.9

26

44

25

35

54

2

4.2

62

66

Ukraine23

37.9

25

15

12

15

65

20

1.3

70

80

United Arab Emirates

9.6

90

15

9

14

83

2

1.4

79

83

United Kingdom of Great Britain andNorthern Ireland24

68.0

–

17

12

18

63

20

1.6

81

84

United Republic of Tanzania25

69.4

24

43

23

33

54

3

4.5

66

70

United States of America26

341.8

132

17

13

19

65

18

1.7

77

82

United States Virgin Islands13

0.1

–

19

13

18

60

21

2.1

71

82

Uruguay

3.4

–

18

14

21

66

16

1.5

75

82

Uzbekistan

35.7

50

30

17

24

64

6

2.7

69

75

Vanuatu

0.3

30

39

22

31

58

4

3.6

69

73

Venezuela (Bolivarian Republic of)

29.4

37

26

19

28

65

9

2.1

69

77

Viet Nam

99.5

111

22

14

21

68

10

1.9

70

80

Western Sahara

0.6

38

24

15

22

70

6

2.2

70

74

Yemen

35.2

31

39

23

32

59

3

3.6

63

70

Zambia

21.1

26

42

24

34

56

2

4.1

61

66

Zimbabwe

17.0

33

40

24

34

57

3

3.3

59

65

150

Indicators

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Demographic indicators
NOTES

DEFINITIONS OF THE INDICATORS− Data not available.

Total population: Estimated size of national populations at midyear.

1

For statistical purposes, the data for Netherlands do not include this area.

2

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

3

Including Nagorno-Karabakh.

4

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

5

As of 1 July 1997, Hong Kong became a Special Administrative Region(SAR) of China. For statistical purposes, the data for China do not include
this area.

6

As of 20 December 1999, Macao became a Special Administrative Region(SAR) of China. For statistical purposes, the data for China do not include
this area.

7

Refers to the whole country.

8

For statistical purposes, the data for Denmark do not include
Faroe Islands and Greenland.

9

Including Åland Islands.

10

For statistical purposes, the data for France do not include French
Guiana, French Polynesia, Guadeloupe, Martinique, Mayotte, New
Caledonia, Réunion, Saint Pierre and Miquelon, Saint Barthélemy, SaintMartin (French part), Wallis and Futuna Islands.

11

For statistical purposes, the data for France do not include this area.

12

Including Abkhazia and South Ossetia.

13

For statistical purposes, the data for United States of America do notinclude this area.

14

Including Sabah and Sarawak.

15

Including Agalega, Rodrigues and Saint Brandon.

16

For statistical purposes, the data for Netherlands do not include Aruba,
Bonaire, Sint Eustatius and Saba, Curaçao, and Sint Maarten (Dutch part).

17

For statistical purposes, the data for New Zealand do not include Cook
Islands, Niue and Tokelau.

18

Including Svalbard and Jan Mayen Islands.

19

Including Transnistria.

20

Including Kosovo.

21

Including Canary Islands, Ceuta and Melilla.

22

Including East Jerusalem.

23

Refers to the territory of the country at the time of the 2001 census.

24

Refers to the United Kingdom of Great Britain and Northern Ireland. For
statistical purposes, the data for United Kingdom do not include Anguilla,
Bermuda, British Virgin Islands, Cayman Islands, Channel Islands,
Falkland Islands (Malvinas), Gibraltar, Isle of Man, Montserrat, SaintHelena and Turks and Caicos Islands.

25

Including Zanzibar.

26

For statistical purposes, the data for United States of America do notinclude American Samoa, Guam, Northern Mariana Islands, Puerto Ricoand United States Virgin Islands.

Population annual doubling time, years: The number of years required
for the total population to double in size if the annual rate of population
change would remain constant. It is calculated as ln(2)/r where r is theannual population growth rate. Doubling time is computed only for fast
growing populations with growth rates exceeding 0.5 per cent.
Population aged 0–14, per cent: Proportion of the population between
age 0 and age 14.
Population aged 10–19, per cent: Proportion of the population between
age 10 and age 19.
Population aged 10–24, per cent: Proportion of the population between
age 10 and age 24.
Population aged 15–64, per cent: Proportion of the population between
age 15 and age 64.
Population aged 65 and older, per cent: Proportion of the population
aged 65 and older.
Total fertility rate: Number of children who would be born per woman if
she lived to the end of her childbearing years and bore children at each age
in accordance with prevailing age-speciﬁc fertility rates.
Life expectancy at birth: 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.

MAIN DATA SOURCES
Total population: World Population Prospects 2022. United Nations
Population Division, 2022.
Population annual doubling time, years: World Population Prospects 2022.
United Nations Population Division, 2022.
Population aged 0–14, per cent: UNFPA calculation based on datafrom World Population Prospects 2022. United Nations Population
Division, 2022.
Population aged 10–19, per cent: UNFPA calculation based on datafrom World Population Prospects 2022. United Nations Population
Division, 2022.
Population aged 10–24, per cent: UNFPA calculation based on datafrom World Population Prospects 2022. United Nations Population
Division, 2022.
Population aged 15–64, per cent: UNFPA calculation based on datafrom World Population Prospects 2022. United Nations Population
Division, 2022.
Population aged 65 and older, per cent: UNFPA calculation based ondata from World Population Prospects 2022. United Nations Population
Division, 2022.
Total fertility rate: World Population Prospects 2022. United Nations
Population Division, 2022.
Life expectancy at birth: World Population Prospects 2022. United Nations
Population Division, 2022.

S TAT E O F W O R L D P O P U L AT I O N 2024

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Technical notes
The statistical tables in State of World Population 2024 include indicators that track progress towards the goals of the Framework of Actions
for the follow-up to the Programme of Action of the International Conference on Population and Development (ICPD), and the Sustainable
Development Goals (SDGs) in the areas of maternal health, access to education, and reproductive and sexual health. In addition, these tables
include a variety of demographic indicators. The statistical tables support UNFPA’s focus on progress and results towards delivering a world
where every pregnancy is wanted, every birth is safe, and every young person's potential is fulﬁlled.
Different national authorities and international organizations may employ different methodologies in gathering, extrapolating or analysing
data. To facilitate the international comparability of data, UNFPA relies on the standard methodologies employed by the main sources ofdata. In some instances, therefore, the data in these tables differ from those generated by national authorities. Data presented in the tables
are not comparable to the data in previous State of the World Population reports due to regional classiﬁcations updates, methodological
updates, and revisions of time series data.
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 estimates and projections from World Population Prospects 2022, and Model-based Estimates and Projections of Family Planning
Indicators 2022 (United Nations Department of Economic and Social Affairs, Population Division). Data are accompanied by deﬁnitions,sources and notes. The statistical tables in State of World Population 2024 generally reﬂect information available as of March 2024.

Tracking progress towards ICPD goals
Sexual and reproductive healthMaternal mortality ratio. Source: United Nations Maternal Mortality
Estimation Inter-agency Group (WHO, UNICEF, UNFPA, The World Bankand United Nations Population Division), 2023. This indicator presents
the number of maternal deaths during a given time period per 100,000
live births during the same time period. Estimates and methodologies
are reviewed regularly by the Maternal Mortality Estimation Inter-agency
Group and other agencies and academic institutions and are revised
where necessary, as part of the ongoing process of improving maternalmortality data. Estimates should not be compared with previous interagency estimates.
Births attended by skilled health personnel. Source: Joint global
database on skilled attendance at birth. UNICEF and WHO, 2023. Thisis the percentage of deliveries attended by health personnel trainedin providing life-saving obstetric care, including giving the necessary
supervision, care and advice to women during pregnancy, labour andthe post-partum period; conducting deliveries on their own; and caring
for newborns. Traditional birth attendants, even if they receive a shorttraining course, are not included.
Number of new HIV infections, all ages, per 1,000 uninfected
population. Source: HIV Estimates. UNAIDS, 2023. Number of new HIV
infections per 1,000 person-years among the uninfected population(SDG indicator 3.3.1).
Contraceptive prevalence, any method and any modern method. Source:
United Nations Population Division, 2022. Model-based estimates are
based on data that are derived from sample survey reports. Survey
data estimate the proportion of all women of reproductive age, andmarried women (including women in consensual unions), currently
using, respectively, any method or modern methods of contraception.
Modern methods of contraception include female and male sterilization,
the intrauterine device (IUD), the implant, injectables, oral contraceptive
pills, male and female condoms, vaginal barrier methods (including thediaphragm, cervical cap and spermicidal foam, jelly, cream and sponge),lactational amenorrhea method (LAM), emergency contraception andother modern methods not reported separately (e.g., the contraceptive
patch or vaginal ring).

152

Unmet need for family planning (any method). Source: United Nations
Population Division, 2022. Model-based estimates are based on datathat are derived from sample survey reports. Women who are using a
traditional method of contraception are not considered as having an
unmet need for family planning. All women or all married and in union
women are assumed to be sexually active and at risk of pregnancy.
The assumption of universal exposure to possible pregnancy among all
women or all married or in union women may lead to lower estimatescompared to the actual risks among the exposed. It might be possible,
in particular at low levels of contraceptive prevalence, that whencontraceptive prevalence increases, unmet need for family planning also
increases. Both indicators, therefore, need to be interpreted together.
Proportion of demand satisﬁed, any modern method. Source: United
Nations Population Division, 2022. Modern contraceptive prevalence
divided by total demand for family planning. Total demand for familyplanning is the sum of contraceptive prevalence and unmet need forfamily planning.
Laws and regulations that guarantee access to sexual and reproductive
health care, information and education, per cent. Source: UNFPA, 2022.
The extent to which countries have national laws and regulations thatguarantee full and equal access to women and men aged 15 years andolder to sexual and reproductive health care, information and education(SDG indicator 5.6.2).
Universal health coverage (UHC) service coverage index. Source:
WHO, 2023. Average coverage of essential services based on tracer
interventions that include reproductive, maternal, newborn and childhealth, infectious diseases, non-communicable diseases and service
capacity and access, among the general and the most disadvantaged
population (SDG indicator 3.8.1).

Indicators Technical notes
Indicators,

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Gender, rights and human capital
Adolescent birth rate. Source: United Nations Population Division, 2024.
Regional aggregates are from World Population Prospects 2022. United
Nations Population Division, 2022. The adolescent birth rate represents
the risk of childbearing among adolescent women 15 to 19 years ofage. For civil registration, rates are subject to limitations which dependon the completeness of birth registration, the treatment of infants born
alive but dead before registration or within the ﬁrst 24 hours of life, thequality of the reported information relating to age of the mother, and theinclusion 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. Source: UNICEF, 2024. Proportion of
women aged 20 to 24 years who were married or in a union before theage of 18 (SDG indicator 5.3.1).
Female genital mutilation prevalence among girls aged 15– 49,
per cent. Source: UNICEF, 2024. Proportion of girls aged 15 to 49 years
who have undergone female genital mutilation (SDG indicator 5.3.2).
Intimate partner violence, past 12 months, per cent. Source: Violence
Against Women Inter-Agency Group on Estimation and Data (WHO,UN Women, UNICEF, United Nations Statistics Division, United Nations
Ofﬁce on Drugs and Crime and UNFPA), 2021. Percentage of everpartnered women and girls aged 15 to 49 years who have experienced
physical and/or sexual partner violence in the previous 12 months(SDG indicator 5.2.1).
Decision-making on sexual and reproductive health and reproductive
rights, per cent. Source: UNFPA, 2024. Percentage of women aged
15 to 49 years who are married (or in a union), who make their own
decisions on three areas — their health care, use of contraception,and sexual intercourse with their partners (SDG indicator 5.6.1).
Decision-making on women’s own health care, per cent. Source:
UNFPA, 2024. Percentage of women aged 15 to 49 years who aremarried (or in a union), who make their own decisions about theirhealth care (SDG indicator 5.6.1).
Decision-making on contraceptive use, per cent. Source: UNFPA, 2024.
Percentage of women aged 15 to 49 years who are married (or in aunion), who make their own decision about use of contraception (SDG
indicator 5.6.1).
Decision-making on sexual intercourse, per cent. Source: UNFPA,
2024. Percentage of women aged 15 to 49 years who are married(or in a union), who make their own decisions about sexual intercoursewith their partners (SDG indicator 5.6.1).
Total net enrolment rate, lower secondary education, per cent. Source:
UNESCO Institute for Statistics, 2024. Total number of studentsof the ofﬁcial age group for lower secondary education who areenrolled in any level of education, expressed as a percentage of thecorresponding population.
Gender parity index, total net enrolment rate, lower secondary
education. Source: UNESCO Institute for Statistics, 2024. Ratioof female to male values of total net enrolment rate for lower
secondary education.

Total net enrolment rate, upper secondary education, per cent.
Source: UNESCO Institute for Statistics, 2024. Total number of studentsof the ofﬁcial age group for upper secondary education who areenrolled in any level of education, expressed as a percentage of thecorresponding population.
Gender parity index, total net enrolment rate, upper secondary
education. Source: UNESCO Institute for Statistics, 2024. Ratioof female to male values of total net enrolment rate for upper
secondary education.

Demographic indicators
Population
Total population, millions. Source: World Population Prospects 2022.
United Nations Population Division, 2022. Estimated size of national
populations at midyear.

Population change
Population annual doubling time, years. Source: World Population
Prospects 2022. United Nations Population Division, 2022. The
number of years required for the total population to double in size
if the annual rate of population change would remain constant. It is
calculated as ln(2)/r where r is the annual population growth rate.
Doubling time is computed only for fast growing populations withgrowth rates exceeding 0.5 per cent.

Population composition
Population aged 0–14, per cent. Source: UNFPA calculation based ondata from the United Nations Population Division, 2022. Proportion of
the population between age 0 and age 14.
Population aged 10–19, per cent. Source: UNFPA calculation based ondata from the United Nations Population Division, 2022. Proportion of
the population between age 10 and age 19.
Population aged 10–24, per cent. Source: UNFPA calculation based ondata from the United Nations Population Division, 2022. Proportion of
the population between age 10 and age 24.
Population aged 15–64, per cent. Source: UNFPA calculation based ondata from the United Nations Population Division, 2022. Proportion of
the population between age 15 and age 64.
Population aged 65 and older, per cent. Source: UNFPA calculation
based on data from the United Nations Population Division, 2022.
Proportion of the population aged 65 years and older.

Fertility
Total fertility rate, per woman. Source: World Population Prospects
2022. United Nations Population Division, 2022. Number of children
who would be born per woman if she lived to the end of her childbearing
years and bore children at each age in accordance with prevailing agespeciﬁc fertility rates.

Life expectancy
Life expectancy at birth, years. Source: World Population Prospects
2022. United Nations Population Division, 2022. Number of years
newborn children would live if subject to the mortality risks prevailingfor the cross section of population at the time of their birth.

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Regional classiﬁcations
UNFPA regional aggregates presented at the start of the statistical
tables are calculated using data from countries and areas asclassiﬁed below.
Arab States Region
Algeria; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; Morocco; Oman;
Palestine; Somalia; Sudan; Syrian Arab Republic; Tunisia; Yemen
Asia and the 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 Statesof); Mongolia; Myanmar; Nauru; Nepal; Niue; Pakistan; Palau; Papua
New Guinea; Philippines; Samoa; Solomon Islands; Sri Lanka;
Thailand; Timor-Leste; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam
Eastern Europe and Central Asia Region
Albania; Armenia; Azerbaijan; Belarus; Bosnia and Herzegovina;
Georgia; Kazakhstan; Kyrgyzstan; North Macedonia; Republicof Moldova; Serbia; Tajikistan; Türkiye; Turkmenistan; Ukraine;
Uzbekistan.
Latin America 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 andNevis; Saint Lucia; Saint Vincent and the Grenadines; Sint Maarten;
Suriname; Trinidad and Tobago; Turks and Caicos Islands; Uruguay;
Venezuela (Bolivarian Republic of)East and Southern Africa Region
Angola; Botswana; Burundi; Comoros; Democratic Republic of theCongo; Eritrea; Eswatini; Ethiopia; Kenya; Lesotho; Madagascar;
Malawi; Mauritius; Mozambique; Namibia; Rwanda; South Africa;
South Sudan; Uganda; United Republic of Tanzania; Zambia;
Zimbabwe
West and Central Africa Region
Benin; Burkina Faso; Cape Verde; Central African Republic; Chad;
Côte d'Ivoire; Equatorial Guinea; Gabon; Gambia; Ghana; Guinea;
Guinea-Bissau; Liberia; Mali; Mauritania; Niger; Nigeria; Republicof Cameroon; Republic of Congo; Sao Tome and Principe; Senegal;
Sierra Leone; Togo
More developed regions are intended for statistical purposes anddo not express a judgment about the stage reached by a particularcountry or area in the development process, comprising UNPD
regions Europe, Northern America, Australia/New Zealand andJapan.
Less developed regions are intended for statistical purposes anddo not express a judgment about the stage reached by a particularcountry or area in the development process, comprising all UNPD
regions of Africa, Asia (except Japan), Latin America and the
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 46 countries (as ofJanuary 2022): 33 in Africa, 8 in Asia, 4 in 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,

154

Kiribati, Lao People's Democratic Republic, Lesotho, Liberia,
Madagascar, Malawi, Mali, Mauritania, Mozambique, Myanmar,
Nepal, Niger, Rwanda, Sao Tome and Principe, Senegal, Sierra
Leone, Solomon Islands, Somalia, South Sudan, Sudan, Timor-Leste,
Togo, Tuvalu, Uganda, United Republic of Tanzania, Yemen andZambia. These countries are also included in the less developed
regions. Further information is available at https://www.un.org/en/
conferences/least-developed-countries.

Note on In Focus: Self-reported
problems in accessing health care, overtime, by socioeconomic status andethnicity (pp. 28–31)
About matching ethnic groups across surveys: This analysis included
matching ethnic groups across the two surveys in each country
and reconciling slight spelling differences or aggregating individual
ethnic groups in one survey to the umbrella ethnic groups usedin the other survey – based on the details provided in individual
country reports’ methodological appendices. Where matches were
not possible, lone ethnic groups were reclassiﬁed to the pre-existing“other” category.
About socioeconomic variables: This analysis included wealthquintile, level of schooling and urban or rural residence. Wealthquintiles divide each country and survey’s population into ﬁve groups
based on a collection of information obtained in the household
questionnaire related to wealth status. Schooling identiﬁes whether awoman has no education, primary, secondary or higher education.
Methodology: Binary logistic regression models were used toestimate the proportion of women reporting serious problems inaccess to health care and to examine country-speciﬁc differencesby ethnicity and socioeconomic status. The regression models take
into account the DHS surveys’ complex survey design and survey
weights to produce valid standard error estimates. Where model
testing indicated it provided a better ﬁt, an interaction between
survey year and ethnicity was included in the models, meaningthat ethnicities had different rates of change over time. Otherwise,
there was no interaction, meaning that ethnicities shared the samerate of change over time but different starting points. The analysis
found ethnic differences in all countries, even after controlling forsocioeconomic status. (In Armenia and Gabon, sample sizes werevery small, meaning the differences seen could be due to statisticalchance.) Multilevel models were used to examine higher-level
patterns across all countries included in the analysis. This analysis
found that, as a general trend, the most marginalized saw the least
improvement in access while the least marginalized saw the mostimprovement. In the models, level 1 was the individual women, level
2 was represented by country-speciﬁc ethnic groups, and level 3
by the 25 different countries. To be more sensitive to the countryspeciﬁc socioeconomic stratiﬁcation, the multilevel models use anindex variable for socioeconomic status instead of the categoricalvariables used in the binary logistic country-speciﬁc regressions. In
the index variable, the socioeconomic proﬁle (a given combinationof wealth, education and residence) with the lowest predictedprobability speciﬁc to each country takes the value of 1, and the
proﬁle with the highest predicted probability takes the value of 40.
All intervening proﬁles take their corresponding value between 1
and 40 according to the ranking of their predicted probabilities in
the country-speciﬁc regressions. Where the analysis refers to the
proportion of women across all countries, these estimates were
derived by weighting the country-level estimates by population size.

Technical notes

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Note on highest and lowest maternalmortality risks, comparing 1990 to 2020
(p. 66)Note on unmet need for contraception
in countries affected by humanitariancrises (p. 95)

In examining trends in maternal mortality from 1990 to 2020
throughout Chapter 3, the authors performed their own calculations
based on data published alongside the most recent ofﬁcial maternalmortality statistics provided in the publication from WHO and others(2023a). The publication itself focuses on trends from 2000 to 2020,
but accompanying data sets include estimates beginning in 1985.
This means that the 1990 and 2020 estimates referred to in Chapter
3 compare estimates derived using the same methodology and input
data. In comparing the 10 per cent of countries with the highest andlowest risk of women eventually dying from pregnancy or childbirth in1990 and 2020, the averages were not weighted by population size.

The authors based this estimate on tabulations of data in Table 2.5of the source, which provides data on the percentage of womenwith met and unmet need for contraception in countries affected byhumanitarian crises in 2015. The percentages with met and unmet
need were summed to compute the total percentage of women
who want to avoid pregnancy in each country. The proportion of
women wanting to avoid pregnancy who are not using any form ofcontraception was computed as the percentage with unmet need
divided by the overall percentage with need. The unweighted averageof the country estimates is 51 per cent.

Note on maternal mortality trend in the
United States (p. 66)
While there are marked racial and ethnic inequalities in maternal
death rates in the United States, maternal mortality ﬁgures in the
country have been increasing across most groups of women. Thereis debate about how much of the increase is an artefact of changing
deﬁnitions and surveillance; these questions cannot be answered
without improved data systems such as systematic and standardized
enquiries into all deaths across all states. Nevertheless, research does
indicate the country’s lack of universal access to health care plays
a role (Braveman, 2023). Notably, a large share of maternal deathsin the country occur between six weeks and one year post-partum,
many of them linked to mental health conditions (Trost and others,2017). Unlike many high-income countries, the United States does notguarantee paid parental leave or home visits by health providers in the
post-partum period (Tikkanen and others, 2020).

Note on per capita income estimatesfrom study in Kenya, Nigeria and Senegal(p. 96)
The authors calculated the per capita income estimates from Table 1of the original source, which estimates the per capita gross domestic
product (GDP) under different scenarios. According to the table, theGDP would be 3,480 international dollars if two thirds of the unmet
need for modern contraception were met (the “moderate” scenario)
and 2,310 international dollars in the baseline scenario.

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Business
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the Law.”
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
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World Economic Forum, 2023. “2024 isYount, Kathryn M. and others, 2022. “GlobalaRecordYear
forElections:
Here’sWhat
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Know.” Website:
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

agenda/2023/12/2024-elections-aroundGoal 5.” BMC Public Health 22: 465.

world/, accessed 8 
February 2024.
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    
Zaneva, Mirela
and others, 2022.
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2021.
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as Victims of Intimate Partner Violence–in Sexual HealthInterventions?
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Examination
Centre.” International
JournalPLoS ONE 17(2): e0261034.
of Legal Medicine 135, 2107–2115.
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  Yadav, Arvind
Pabitra K. Jena,        2020. “Maternal Health Outcomes of         
Socially Marginalized Groups in India.”            International Journal of Health Care       
QualityAssurance
33(2): 172–188.
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Yang, Fanand others, 2020.
“Key

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and¡
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
The Lancet HIV 7(1): e69–e74.
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                    ¢ ¡       
  ¢          
  ¡    
   
£¤       
£¤    £¤ £ ¤     
                   
        
 
           ¢       
         ¥      
 
      

Ensuring rights and choices for all
168

References

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state of world population 2024

Interwoven Lives, Threads of Hope

Ensuring rights and choices for all

ISSN 1020-5195
ISBN 9789210031318

United Nations Population Fund
605 Third Avenue
New York, NY 10158
Tel. +1 212-297-5000
www.unfpa.org@UNFPA

Sales No. E.24.III.H.1
E/700/2024

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