Patchy progress on the ICPD: are we asking the right questions?
Authors: Dorothy Shaw
Journal: The Lancet Global Health (2020)

The International Conference on Population and Development (ICPD) agenda, set in 1994 in Cairo and revisited 25 years later in Nairobi in 2019, included goals for equitable education of women, reduction of infant and child mortality, reduction of maternal mortality, and access to reproductive and sexual health services, including family planning, through its well known Programme of Action.1United Nations Population fundInternational Conference on Population and Development.https://www.unfpa.org/icpdGoogle Scholar The ICPD was ground-breaking in recognising the benefits that empowerment of women and girls would have for themselves, their families, and, ultimately, their countries. Notably, 179 countries signed onto the Programme of Action and focused efforts on providing access to contraception as a basic human right. Yet progress on these goals has been patchy, as evidenced by the advocacy for a late inclusion of contraceptive prevalence as target 5B in the Millennium Development Goals,2United NationsMillennium Development Goals and beyond 2015. Goal 5: improve Maternal Health. Target 5.B: achieve, by 2015, universal access to reproductive health.https://www.un.org/millenniumgoals/maternal.shtmlGoogle Scholar and the indicator for the current Sustainable Development Goal (SDG) 3.7.1 to meet 75% of the demand for family planning in all countries by 2030.3United NationsResolution adopted by the General Assembly on 25 September 2015. 70/1. Transforming our world: the 2030 Agenda for Sustainable Development.https://sustainabledevelopment.un.org/post2015/transformingourworldGoogle Scholar In 2019, the reported estimates varied from 51·1% to 90·1% depending on the country.4United Nations Department of Social and Economic AffairsPopulation Facts July 2019 | No. 2019. Global progress in satisfying the need for family planning.https://www.un.org/en/development/desa/population/publications/pdf/popfacts/PopFacts_2019-3.pdfGoogle Scholar Using an in-depth retrospective regression and principal component analysis, Emma Slaymaker and colleagues have provided harmonised nationally available data from 74 countries to evaluate progress on the ICPD agenda using a broader social context than just contraceptive targets, including life events such as age of sexual initiation, first union (cohabitation or marriage), and first birth; sexual behaviour; and social and economic indicators, such as gross domestic product (GDP) per capita, indices of gender development and inequality, and female and male expected years of education.5Slaymaker E Scott RH Palmer MJ et al.Trends in sexual activity and demand for and use of modern contraceptive methods in 74 countries: a retrospective analysis of nationally representative surveys.Lancet Glob Health. 2020; (published online March 9)https://doi.org/10.1016/S2214-109X(20)30060-7Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar This study provides useful insights by using a comprehensive approach, underscoring continuing societal changes that affect the length of time after sexual initiation to first union and first birth, which can lead to additional time using modern methods of contraception. Although only at the national level, data on sexual activity, demand for contraception, and use of contraception were correlated with the gender development index and expected years of education for females in the 67 countries with data available. In the subset of 46 countries suitable for principal component analysis, which included data on men and women, further correlations were found with life events and social structural variables such as education for both sexes and GDP per capita. Concurrent with other studies, length of education correlated positively with use of modern contraceptive methods and, along with other evolving societal norms, was a significant driver of increased demand across the age group 15–49 years, rather than only in those aged 15–24 years. The gender development index also correlated positively with use of contraception, although subnational data and in-country inequities were, again, not available. Disappointingly, only 74 countries were found to have adequate data for the analysis and data harmonisation, with many countries having no surveys and a lack of congruency of instrument questions between those from high-income countries and those from low-income and middle-income countries, especially where sex before marriage is taboo. Inclusion of high-income countries is of relevance, given that the SDG goals apply to all 193 countries that adopted the 2030 SDG agenda at the United Nations General Assembly in September, 2015. All countries face important inequity challenges, given the social determinants of health affecting sub-populations such as adolescents, migrants, refugees, and the urban poor. Of note in the results is that women who were sexually active in the past year proportionately increased in 43 of the 74 countries, with an increased demand for contraception in 42 countries, but only 37 of these countries reported a concurrent increase in contraceptive use. Also of concern is the finding that use of a modern contraceptive method by women not wanting to conceive proportionately decreased over time in six countries, although modern method use expanded in some of these countries. This result deserves further enquiry, as does the increasing group of women in 14 countries, including the USA, who do not want to conceive but are not using a modern method of contraception, to determine underlying issues that could be addressed, such as barriers from partners, providers, cost, information, and other factors affecting access. This study suggests that the complexity of context requires a standardised global survey instrument, with longitudinal tracking, addressing the broader social context; data should be disaggregated at the subnational level, especially for populations known to face increased challenges in access to care and services, to determine gaps in services and policy. Questions would include the sexual behaviour of men and women, disaggregation of women by age—as in Slaymaker and colleagues' study—and social context questions regarding challenges in accessing contraception, including coerced sex, intimate partner violence, cost, and provider attitudes. Contraceptive method and pregnancy history are increasingly relevant as changes in methods frequently occur with longer duration of use, and contraceptive failure accounts for about half of women presenting for an abortion.6Jones RK Reported contraceptive use in the month of becoming pregnant among US abortion patients in 2000 and 2014.Contraception. 2018; 97: 309-312Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Inclusion of emergency contraceptive use, post-abortion care, and post-partum contraception is important, with provision for privacy and confidentiality, as with sexual behaviour and violence. With the efforts towards meeting contraceptive needs over the past 25 years, one might have expected better progress, but it is time to consider the context of women's lives more broadly to meaningfully address gaps not anticipated by the ICPD. If focused solely on counting the number of women expressing met and unmet need, countries across the world are likely to miss yet another goal, since gender equality and increasing population size are yet to fully manifest their impact. I declare no competing interests. Trends in sexual activity and demand for and use of modern contraceptive methods in 74 countries: a retrospective analysis of nationally representative surveysProgress towards satisfying demand for contraception should take account of the changing context in which it is practised. To remove the remaining barriers, policy responses—and therefore research priorities—could require a stronger focus on social-structural determinants and broader aspects of sexual health. Full-Text PDF Open AccessNo time for complacency on the road to gender equalityInternational Women's Day, on March 8, is a chance to look ahead to some crucial events later this year on the ongoing agenda to create an equitable world for women and girls. On March 9, the 64th session of the UN Commission on the Status of Women was set to adopt a political declaration reaffirming commitments made in the 1995 Beijing Declaration and Platform for Action . That landmark document, the outcome of the Fourth World Conference on Women in Beijing, China, is celebrating its 25th anniversary this year. Full-Text PDF Open Access