EMERGING CONCEPTS IN REPRODUCTIVE HEALTH AND RIGHTS NEEDS CLEARER DEFINITIONS, POPULATION AND DEVELOPMENT COMMISSION TOLD IN ICPD FOLLOW-UP DISCUSSION
Press Release
POP/609
EMERGING CONCEPTS IN REPRODUCTIVE HEALTH AND RIGHTS NEEDS CLEARER DEFINITIONS, POPULATION AND DEVELOPMENT COMMISSION TOLD IN ICPD FOLLOW-UP DISCUSSION
19960226 The need for clearer definitions of emerging concepts in the field of reproductive rights and reproductive health was stressed today by speakers addressing the Commission on Population and Development, as it began consideration of follow-up to the recommendations of the 1994 International Conference on Population and Development.The question of what constituted 'entry into reproductive life' was raised by the representative of Jamaica, who said that age at first marriage had been extended to include consensual unions and visiting relationships. He suggested that perhaps more specific concepts, such as 'age of entry into unions', could be employed.
The representative of France said the variety of forms of marriage and its decreased importance in light of cohabitation introduced great heterogeneity in comparisons. The representative of Malta said he was not aware that there was a definition of marriage in United Nations documents. Cohabitation was being discussed as an alternative to marriage, but this did not seem to be based on any international document, he added.
The representative of the United States stressed the need in all countries to recognize and respond to the problem of adolescent childbirth. "Young men and women are becoming sexually active earlier and they are marrying later." Their special needs for reproductive health services must be met, he said.
The representative of Mexico said there was a need for a new approach to compiling comparative statistics that would incorporate the gender perspective in greater depth. Unfortunately the analysis had almost exclusively covered women. He recommended that the gender perspective be highlighted.
Other statements on follow-up to the recommendations of the International Conference on Population and Development were made by the representatives of the United Kingdom, Belgium, Nigeria, Canada and the Philippines. Statements in general debate were made by the representatives of Ukraine, Netherlands, Egypt, Jamaica, United Republic of Tanzania, Nicaragua, Peru and Bangladesh. The observer for the Holy See also spoke.
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Introducing reports before the Commission were Joseph Chamie, Director, Population Division; Birgitta Bucht, the Division's Assistant Director; and Jyoti Singh, Deputy Director of the United Nations Population Fund (UNFPA).
The Commission on Population and Development will meet again at 10 a.m. tomorrow, 27 February, to continue its general debate and to take up the monitoring of population programmes.
Commission Work Programme
The Commission on Population and Development met this afternoon to continue its general debate. It is also scheduled to take up follow-up actions to the recommendations of the International Conference on Population and Development (Cairo, 1994) concerning reproductive rights and reproductive health.
Concerning follow-up to the International Conference on Population and Development, the Commission has before it the Secretary-General's report on world population monitoring, 1995: reproductive rights and reproductive health (document E/CN.9/1996/2). The report summarizes recent information on selected aspects of those issues, including entry into reproductive life; reproductive behaviour; contraception; abortion; maternal mortality and morbidity; sexually transmitted diseases; and population information, education and communication.
The report recalls the definition of reproductive health -- a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes. "Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so." The definition of reproductive rights recognizes the basic right of couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to make decisions concerning reproduction, free of discrimination, coercion and violence.
Concerning entry into reproductive life, the report states that adolescence is increasingly recognized both as an important determinant of future health and as a specially vulnerable period of life. In particular, increasing concern has been expressed about sexual risk-taking among young people, which can cause teenage pregnancy and the spread of sexually transmitted diseases, including HIV.
Traditionally, age at marriage has been regarded as marking the initiation of sexual activity and, therefore, the beginning of exposure to reproduction. The report finds a global shift towards later marriage, which is most pronounced in Asian countries. In Africa, the reduction in the average proportion of people married by age 20 has been almost as sharp -- from 72 per cent to 55 per cent -- but the prevalence of teenage marriage remains much higher than in Asia. In Latin America and the Caribbean, changes in the timing of first marriage have been more modest. Age at marriage for women has also risen in the past 20 years in the developed countries, although information on trends in age at marriage is not comparable to that for
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developing countries because most data derived from civil registration deal with legal marriage only.
In most countries there is a general trend towards later marriage with increased educational level. Data show that women with at least 10 years of education marry between two and seven years later than those with less than primary education. Delays in the timing of first marriage have played a key role in the fertility decline in many countries because most births continue to occur within marriage. Increases in the age at marriage, however, do not necessarily translate into the shortening of the reproductive life span. Premarital births are increasing in a number of countries around the world. Furthermore, the prevalence of sexually transmitted diseases among unmarried adolescents suggests that premarital sexual activity is not uncommon and may be increasing.
The report goes on to say that in most areas of the world, men report an earlier age at sexual initiation than women, a greater number of partners and a longer period between sexual initiation and marriage. They are more likely than women to report premarital sexual activity. Age differences between partners have important implications for the transmission of sexually transmitted diseases. Men typically have younger female partners, which increases the vulnerability of younger women to sexually transmitted diseases and HIV infection.
In the industrialized countries, there are indications of an increase in the overall proportion of young people who are sexually active. Age at marriage has increased; there is evidence of a fall in the age of sexual initiation; and a greater proportion of adolescents are involved in cohabiting relationships.
Concerning reproductive behaviour, the report states that the current total fertility rate for the world as a whole is estimated to be 3.1 children per woman. "This average, however, conceals a large diversity between and within regions." The highest total fertility rate is observed in Africa, with 5.8, followed by Latin America and the Caribbean, with 3.1 and Asia, with 3.0. Although adolescent fertility is increasingly perceived as an issue of social and policy concern, fertility rates among women under age 20 have been falling alongside overall fertility rates worldwide, owing to rising age at marriage, increasing educational opportunities for young women and increased use of contraception. "There are, however, some exceptions to the overall downward trend, for example in Haiti, India and the United States."
Stressing that marriage is not the only context within which child- bearing takes place, the report says that in many developed countries, the rapid increase in child-bearing outside marriage, closely linked to the rise in cohabitation, constitutes one of the most significant recent transformations in family-building patterns. In the developing regions, out- of-wedlock child-bearing is relatively rare in Asia, but commonplace in Africa and Latin America and the Caribbean, reflecting the high prevalence of consensual unions.
"The prevailing gap between women's ideal family size and actual child- bearing suggests that women's reproductive aspirations are seldom fulfilled", the report continues. The inadequate control women have over their
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reproduction is also evident from the high prevalence of unplanned child- bearing. In the developed countries, a family with two children is the dominant ideal and, in many cases, the preferred number of children is above the actual total fertility rate. However, the number of unintended births is relatively large, despite the high prevalence of contraceptive use.
Addressing the problem of infertility, the report states that between 8 per cent and 12 per cent of all couples experience some form of it during their reproductive lives. In a small proportion of couples -- under 5 per cent -- the underlying causes of infertility are attributable to anatomical, genetic, endocrinological or immunological factors. However, in the majority of cases, problems of infertility arise from preventable causes, such as untreated infection from sexually transmitted diseases, post-partum and post-abortion complications or female genital mutilation. Studies have found an unusually high incidence of impaired fertility in Africa, particularly in central Africa.
While noting the importance of control over fertility in reducing maternal mortality, the report states that socio-economic conditions, education, nutrition and health care are often more important determinants of women's health and survival.
The transformation in contraceptive practice reflects the growing desire of couples and individuals to have smaller families and to choose when to have their children, the report continues. Most users of contraception are women and most of them use modern methods. However, some countries in eastern Europe show high prevalence levels of traditional methods such as the Czech Republic, Romania and Slovakia. Where data is available, most developing countries show a substantial recent increase in contraceptive use.
The report cites the rising use of female sterilization as the most important trend in both developed and developing countries. Recent surveys indicate a significant rise in the level of use of condoms in several countries, suggesting that campaigns promoting this method are having an effect. Despite the recent rapid growth in the use of contraception, a variety of indicators suggest that the level of unmet need remains high. About 20 per cent to 25 per cent of couples in developing countries (except China) are at risk of an unwanted or mistimed pregnancy because they do not use contraceptives. In Africa and in some countries in other regions,
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substantial proportions of the population still have no knowledge of any type of contraception.
In general, the report continues, problems of limited knowledge of and access to family planning reflect the difficulty many governments have experienced in extending services nationwide rather than a deliberate policy to restrict access. By 1995, only two governments (out of 190) had an official policy of limiting access to modern contraceptive methods, while 82 per cent of the governments provided direct support for family planning services.
The report goes on to say that side-effects and worries about them stand out consistently in studies of different populations as one of women's major concerns about modern contraceptive methods. Health concerns and side-effects are frequently cited as the reason for discontinuing the methods, and in many cases a substantial proportion of women who are at risk of an unwanted pregnancy report that health concerns are their main reason for not using contraception. At the same time, the recent rise in the level of contraceptive use is due almost entirely to increased use of modern methods. "The evidence suggests that, although modern methods have worked well for many couples, their use still presents difficult choices for many others."
Recently, surveys have begun to ask men what women had long been the focus of: questions about contraceptive use. The information, which is only now beginning to be analysed, indicates that in some countries a substantial proportion of the women with an apparent unmet need for contraception report that they are not using any method because of opposition from their spouse. "Some men clearly do expect to make the choice about using contraception (even if it is the woman who uses the method), while others view this as being completely the woman's responsibility. In some countries, many people do not know their partner's views about family planning."
In its section on abortion, the report states that 25 million legal abortions were performed worldwide around 1990. "This estimate must be considered the minimum number of legal abortions, as no attempt has been made to estimate the magnitude of unreported legal abortions." The World Health Organization (WHO) has estimated that some 20 million unsafe abortions are performed each year. In countries where abortion is legal and widely available, abortions generally pose a relatively small threat to women's reproductive health. Where abortion is illegal, however, it is usually performed in medically substandard and unsanitary conditions, leading to a high incidence of complications and resulting in chronic morbidity and often death. More than 70,000 women are estimated to die annually as a result of complications arising from unsafe abortion.
Lack of legal restrictions on abortion does not necessarily guarantee access to safe abortion, the report states, citing the relatively high
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incidence of unsafe abortion in the former Soviet Union, despite the availability of abortion on request since 1956.
Adolescent abortion is a growing area of concern, the report continues. Because adolescents are sometimes unwilling or unable to seek appropriate health care or wait longer in the gestation period to obtain help, induced abortion generally presents a greater risk to the health and life of the adolescent than to an adult woman.
Abortion to preserve the woman's physical health is permitted in 119 countries. Ninety-five countries allow abortion to preserve the woman's mental health, and 81 permit it when pregnancy has resulted from rape or incest. The number declines to 78 countries when there is the possibility of foetal impairment and to 55 countries when there are economic or social reasons. Finally, in 41 countries, abortion is available on request.
In its section on maternal mortality, the report states that new statistical methods indicate maternal mortality is higher than previously estimated, with some 590,000 maternal deaths per year. The report provides statistical breakdowns of the causes of maternal deaths by region. It states that abortion is likely to account for a larger percentage of overall maternal mortality in Latin America although the maternal mortality ratio is generally lower in that region than in most parts of Africa.
The complications that cause the deaths and disabilities of mothers also damage the infants they are carrying, according to the report. Every year there are 5 million neonatal deaths, of which 3.5 million occur within the first week of life and are largely a consequence of inadequate or inappropriate care during pregnancy, delivery or the first critical hours after birth. And for every newborn death another infant is stillborn. "The paucity of information about maternal ill-health has resulted in long neglect of the problem, neglect that the international community has only recently started to address."
Regarding sexually transmitted diseases, the report states that their prevention and control has until recently been a low priority for most countries and development agencies. To date, most programmes for the prevention of sexually transmitted diseases have focused on prevention of complications, or what is referred to as secondary prevention. The prevention of transmission of infection -- primary prevention -- is at present receiving increased attention because of the global HIV/AIDS epidemic and the identification of several sexually transmitted diseases as risk factors for the spread of HIV.
The HIV epidemic continues to grow with thousands of new infections occurring every day. An estimated cumulative total of 18.5 million adults and 1.5 million children have been infected with HIV, according to the report.
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During the current decade, the WHO forecasts that by the year 2000, 30 million to 40 million HIV infections will have occurred, 90 per cent of which will be in developing countries. The epidemic is having devastating effects on individuals, families and entire communities. Young people are particularly affected by HIV and AIDS; it is estimated that 50 per cent of HIV infections occur in age group 15-24.
According to the report, it is estimated that about 333 million curable cases of sexually transmitted diseases occur globally every year, most of which are occurring in developing countries. "Sexually transmitted diseases have been a neglected area in public health in most of the developing countries despite the overwhelming facts of their impact on health, particularly for women and newborns." For several decades, sexually transmitted diseases have ranked among the top five conditions for which adults in many developing countries seek health-care services. In most industrialized countries, on the other hand, there has been a spectacular decline in the incidence of sexually transmitted diseases, particularly gonorrhoea and syphilis.
The report goes on to state that women, especially young women, are more vulnerable than men to infection with a sexually transmitted disease and its complications, such as infertility, cancer and inflammatory diseases. Biologically women are more susceptible to most sexually transmitted diseases than men. Women with a sexually transmitted disease are more likely than men to be asymptomatic, and, therefore, are less likely to seek treatment, resulting in chronic infections with more long-term complications and sequelae.
There are important overlaps between programmes for the prevention of HIV/AIDS and sexually transmitted diseases and care programmes and other components of reproductive health programmes, according to the report. Family planning services and maternal health care services offer an important opportunity for both diagnosis and treatment of sexually transmitted diseases, as well as information about their prevention, including safer sexual behaviour and related services such as the provision of condoms.
Addressing what it terms the "particularly controversial topic" of reproductive rights and reproductive health, the report states that they include not only the right of all couples and individuals to decide freely on if and when to have children, but also the right to attain the highest standard of sexual and reproductive health and the right to make reproductive decisions free from discrimination, violence and coercion. One of the cornerstones of the concept of reproductive rights is the right of access to methods of family planning.
Adolescent reproductive behaviour has become an emerging world-wide concern, the report states. Most countries do not have coherent policies for
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the protection and maintenance of reproductive health in adolescents, partly because of the sensitivity of the subject. Many women are not aware that they have reproductive rights; without such awareness they are unlikely to exercise those rights.
Social and cultural obstacles restrict the scope of action to achieve reproductive rights and health, but the strategies that can be employed are discussed in the report. Education can serve to furnish basic facts on the reproductive system. Publicity can be given to the existence of the international texts supporting reproductive rights. Such information should be provided to medical personnel, religious leaders, government officials and non-governmental organizations. "Of critical importance is presenting the concept of reproductive rights in ways that are appropriate at the local level."
Effective advocacy is essential in creating awareness of reproductive rights and reproductive health and can be facilitated by the use of effective information, education and communication strategies, according to the report. Because of the critical stage of their personal development, young people, particularly adolescents, have a special need for information on sexual and reproductive health. The provision of information about sexuality, pregnancy and sexually transmitted diseases, combined with information about local services and counselling availability, is an effective way of assisting young people.
Statements in Debate
MYKOLA BORYSENKO (Ukraine) said the demographic situation in Ukraine was characterized by low rates of reproduction. The main problem was the country's deteriorating environment. One country on its own could not solve its environmental problems; a regional approach was required. In particular, the Chernobyl disaster's consequences could be compared to those of the Second World War. The Chernobyl accident had resulted in increased mortality. "The real scales of this disaster are far greater than those originally ascribed to it." The disaster had contributed to the demographic crisis, which was marked by worsening health. The number of families having no children or one child was increasing, so the population was not growing.
Ukraine was paying particular attention to the issue of migration, especially the reintegration of Crimean Tartars, he continued. A "brain drain" was taking place in Ukraine; in 1995, nearly 300,000 people had left the country for permanent residence abroad. Among them had been large numbers of specialists and people of working age. The rights of immigrants must be defended.
He said that Ukraine was working to support mothers and children through such measures as the provision of paid maternity leave. The Government's
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priority was to improve living conditions for its citizens, including through combating alcohol and drug abuse and working to prevent the spread of HIV/AIDS. Ukraine provided family planning programmes so that individuals had free choice with respect to reproductive matters.
JENNY GIERVELD (Netherlands) said Dutch policy would continue to focus on reproductive health and reproductive rights and to involve men in programmes related to those issues. Recent developments in reproductive behaviour was being carefully examined for use in formulating policy in the years to come. Although there was a rise in couples living together outside of marriage and also in the number of children being born outside of marriage, rates of extramarital births in his country were still relatively low. Nevertheless, the Netherlands still lagged behind other European countries with regard to day-care centers.
She said a large percentage of pregnancies were concentrated in women above the age of 30, resulting in more complications. However, Dutch policy was that they should be able to decide freely on the number of children they wanted and the spacing of those children. The Government had introduced new policies offering women and men better opportunities to combine the roles of parenting. There is now parental leave for both men and women.
The increasing numbers of the elderly had grown hand in hand with the rise of one-person households, especially among women, she said. The needs of the ageing population needed careful monitoring. The position of the older female population and their integration into society had to be included in the discussion of the status of women.
MOSHIRA ELSHAFEI (Egypt) said her country placed priority on meeting unmet family planning needs. Some 18 per cent of the population was not receiving services. To reach those people, the Government was working to provide services to small communities in remote desert areas. Egypt was also working to improve the quality of services. Counselling had become an integral part of the reproductive care of women. In private counselling, women could ask questions about sexuality and reproduction that they would not otherwise ask. The private sector was playing a key role in covering the country's family planning needs. Egypt was working to increase the involvement of men in reproductive matters.
Human resources development was a major component of Egypt's population programme, she said. People were being trained in the fields of reproductive rights and reproductive health through workshops designed to follow-up on the decisions of the International Conference on Population and Development. Non- governmental organizations had played a key role in population programmes. Research in the area of population had revealed that the country had several population-related problems in upper Egypt. Subsequently, programmes had been designed to reach women in that region. Egypt had adopted an integrated
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approach to population and development. Special attention was being paid to female literacy. Work was under way to build 3,000 classrooms to provide education and training to girls.
EASTON WILLIAMS (Jamaica) said the total fertility rate of about three children per women had not changed in recent years. Teen pregnancy was a major concern. Jamaica's reproductive health programme had long been highly developed, but it received new impetus following the adoption of the Cairo Programme of Action. Since the Conference, maternal and child health planning programmes had been integrated with programmes geared towards the prevention and control of HIV and other sexually transmitted diseases. Traditionally, sexual and reproductive health programmes had been biased towards females, but since the Cairo Conference, efforts had been made to incorporate males in those concerns.
Family life education was of paramount importance in Jamaica, he said. The National Family Planning Board had launched a personal choice programme aimed at involving the private sector in the provision of services. Jamaica had developed a national plan of action on population and development in keeping with the objectives of the Cairo Conference. It had also adopted a plan of action to eradicate poverty in light of the recommendations of Cairo.
U.P. TENENDE (United Republic of Tanzania) said his Government attached great importance to the Population Conference Programme of Action which had contributed much to the national programme in his country, including the areas of reproductive rights and reproductive health. In 1996 Tanzania had organized a seminar for members of Parliament to acquaint them with the outcome of the Conference. The basic premises of sectoral plans included the involvement of communities and civil societies at the grass-roots level as success depended on community involvement. Community involvement was also one way of guaranteeing domestic participation, he added.
He said community service projects were operating now in a few districts with plans to cover the whole country in the near future. The involvement of non-governmental organizations and the private sector was encouraged. With the growing maturity of non-governmental organizations, it was expected that a larger proportion of the national programme would be carried out by non- governmental organizations and the private sector. In the meantime, the Government was committed to allocating more resources to current programmes and creating new programmes in the future.
He expressed appreciation for the assistance provided for the international community and looked forward to a continued relationship with those parties.
Bishop JAMES MCHUGH, observer for the Holy See, said that the Holy See's world-wide network of hospitals and other facilities provided a number of
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services to women and children. In keeping with its desire to promote reproductive health, the Holy See had sponsored a conference on breast-feeding at which scientists had discussed the advantages of that practice as well as its social and demographic implications. The Holy See had also issued guidelines for education on sexuality within the family. The document provided information based on the dignity of the individual, as well as guidelines for parents to help them to fulfil their roles. Pope John Paul II had issued a comprehensive statement on the protection of the unborn in which he directed Catholic agencies to help families, mothers and children.
MARIO CASTELLON (Nicaragua) said until the 1940s, his country's population had been stable. Since then, the size of the national population had more than tripled. There had been marked inequality in some areas where people were living with little access to resources. Conditions of social marginalization were obstacles to social redress. The Government had developed projects to reach those underserved populations. Strategies were focused on promoting community participation, with emphasis on the poorest people. Some of the Government's objectives to reduce maternal mortality and the number of births had been achieved. The governmental sectors in those areas had earmarked funds to achieve the commitments made at the Cairo Conference.
MARIA CRISTINA LOPEZ (Peru) said her Government was ready to implement the commitments undertaken in Cairo. It planned to grant access to family planning to the poorest part of the population as part of the strategy to fight poverty.
The question of population was closely linked to the gender issue, she said. Women had the right to decide freely on the number of children they should have. The family planing programmes instituted by the Ministry of Health had been strengthened. Sex education would be an integral part of the formal education sector. In 1995, funding provided to social assistance programmes had been doubled, 200 per cent of what was suggested at the Social Summit in Copenhagen. The Congress had changed the family laws to include sterilization as a method of family planning. Abortion was excluded.
She said the Government would fight poverty by increasing employment and establishing micro-enterprises; social investment projects had generated some 800,000 new jobs. It had also strengthened institutions and increased spending for the provision of basic needs to the poorest of the population. Further, the Government had set up family planning and reproductive health programmes. The Ministry of Health had greatly improved its management programmes. The national health policy through the year 2000 focused on fecundity and infant mortality, in an effort to develop a social model to help people achieve their greatest potential.
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SYED AHMED (Bangladesh) said his country was the ninth most populous State in the world, with some 120 million people. Bangladesh had about 800 people per square kilometre -- the densest population in the world. Annual per capita income was about $220. Over the past two decades, Bangladesh had distinguished itself through its declining fertility rates, which had been an average of 7.5 children per woman in 1974 and had gone down to 3.5 in 1994. The infant mortality rate had declined from 150 per 1,000 live births in 1975 to 88 per 1,000 in 1992. Coordinated and substantial donor support as well as private sector funding had contributed to Bangladesh's successes.
In the future, Bangladesh would focus on the delivery of quality health services, he said. The maternal mortality rate was still high, and the questions of child survival, malnutrition and disease remained matters of concern which would receive high priority. Bangladesh looked forward to continued collaboration with donors in the field of population. It also envisaged an increased role for non-governmental organizations and the private sector in reducing the Government's burden of funding population programmes.
Statements on Reproductive Rights, Health
JOSEPH CHAMIE, Director of the Department for Population Division, said the reports before the Commission revealed great international cooperation between the United Nations and various intergovernmental and non-governmental organizations. Improvements in technology had strengthened cooperation. The Division would be open to suggestions, based on the current discussion of reproductive health and reproductive rights, concerning how to prepare for next year's session.
BIRGITTA BUCHT, Assistant Director, Population Division, introduced the Secretary-General's concise report on world population monitoring. "As far as possible, we have tried to cover both men and women in this report. But, data collection and research have until recently mainly focused on women." Information was also lacking on the reproductive health of young adolescents and of older men and women, who were usually not the subject of surveys. She said she welcomed comments and suggestions on the report, which would be revised before publication based on the Commission's discussions.
JOHN HOBCRAFT (United Kingdom) said that his country had been active in requesting that the Secretary-General's concise report be prepared for this meeting. His confidence in the Secretariat's capacity to produce the report had been borne out and the report was a benchmark document.
He said the report covered many important areas, and he welcomed the emphasis on adolescent sexual and social behaviour. An issue that arose was what was left out as well as what had been included. It pointed out the lack of information on reproductive morbidity and the need for the development of new indicators in the collection of information in those areas. There were
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still considerable gaps in current knowledge.
He urged caution in the classifying "birth order of four and higher" as high risk births, warning that the term high risk births might subsequently be misused. He also urged that the Division look at means of making the report widely accessible and to provide as many stark facts as possible.
ROBERT LOUIS CLIQUET (Belgium) said the concise report was an excellent overview of the major population issues in the spirit of the Cairo Conference. Unqualified freedom for reproduction was incompatible with sustainability. Responsibility with respect for reproductive matters was more important than freedom. The report noted that the postponement of childbirth in developed countries might pose problems for women. Both the postponement of childbirth up to the thirties as well as the deficit in fertility showed in industrialized countries showed that those States had not succeeded in combining female career development and fertility.
EASTON WILLIAMS (Jamaica) commended the Population Division for the introduction of innovative concepts in the concise report, such as 'age of entry into reproductive life'. More clarity, however, was needed in the use of such concepts. For example, age at first marriage had been extended to include consensual unions and visiting relationships. Perhaps more specific concepts, such as 'age of entry into unions', could be employed.
AMBROSE D. OJIMBA (Nigeria) said the concise report was very comprehensive, but it did not adequately highlight the importance of education and population information. "Some of the terms are hanging in the air." The report should highlight the critical role of public awareness programmes by providing information on what governments had done in that regard.
Ms. GIERVELD (Netherlands) joined others in complementing the report. The morbidity figures were not presented as clearly as they could be. The report rightfully pointed out that maternal mortality was a sensitive indicator of the status of women.
RICHARD CORNELIUS (United States) also commended the report as an excellent overview of the demographic situation in the world. The report's contents deserved widespread dissemination in an attractive format that would be useful to policy makers. The report underscored the need in all countries to recognize and respond to the problem of adolescent childbirth. "Young men and women are becoming sexually active earlier and they are marrying later." Their special needs for reproductive health services must be met. The dissemination and expansion of reproductive rights should be at the heart of all population programmes and the future work of the Commission.
JOSE DE LEON (Mexico) said the report had diligently provided statistics that were produced by the report of the World Fertility Survey and the
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subsequent investigations by the Demographic and Health Surveys. Referring to the conceptual approach marking the difference between two, he emphasized that the coverage of health was essential in the Commission's deliberations, in particular the more comprehensive aspect of reproductive health.
He said there was a need for a new approach to compiling comparative statistics that would incorporate the gender perspective in greater depth. Unfortunately the analysis had almost exclusively covered women. He recommended that the gender perspective be highlighted.
RUTH ARCHIBALD (Canada) said many of the chapters were written by different people. The format should be more consistent in follow-up documents. She supported the suggestion of the United States particularly in chapter seven concerning the issue of reproductive health.
JACQUES VERON (France) said the variety of forms of marriage and its decreased importance in light of cohabitation introduced great heterogeneity in comparisons. It would be useful to examine questions in greater depth concerning mortality and morbidity in light of sexual behaviour.
LIBRAN CABACTULAN (Philippines) said it was not possible to do justice to the report having only received it recently. He questioned the indicators on legal abortion, and said that there was a dearth of data on reproductive morbidity perhaps because that issue had not received due attention. There seemed to be a need to develop an indicator of quality care, since the emphasis had shifted from quantity to quality.
Ms. BUCHT, Assistant Director, Population Division, said it was hoped that the report would serve as a timely and useful contribution to the work of the Commission. With respect to the comments calling for more information on morbidity, she said that in preparing the report, it had been decided to defer detailed discussions of the matter to the next report, at which time the focus would be mortality and morbidity. The Secretariat would take account of the need for full and clear definitions. The report did discuss the different forms which marriage could take and its impact on comparisons. Marriage could take many forms, making it difficult to assess its relation to childbearing. There was a need to collect increased data on men.
VICTOR PACE (Malta) said he was not aware that there was a definition of marriage in United Nations documents. Cohabitation was being discussed as an alternative to marriage, but this did not seem to be based on any international document.
Mr. CLIQUET (Belgium) said that in countries with high contraceptive prevalence, legalized abortion decreased overall abortion rates.
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Monitoring of Population Programmes
JYOTI SINGH, Deputy Director of United Nations Population Fund (UNFPA) introduced the report of the Secretary-General on the monitoring of population programmes (document E/CN.9/1996/3). The report gives a broad overview of the range of activities that have been initiated by the UNFPA in the aftermath of the International Conference on Population and Development in the areas of reproductive rights, reproductive health and population information, education and communication. It assesses different approaches by developing States and countries in transition to implementing their own activities in those areas, and analyses constraints encountered in that process. The information in the report is based on a questionnaire filled out by UNFPA representatives in 78 countries.
Despite encouraging signs of commitment and dedication to reproductive health programmes, the socio-economic and cultural environment is not always conducive to change. On a national level, widespread poverty severely hampers the abilities of governments to fully implement such programmes, limiting people's access to reproductive health care. Many obstacles still need to be overcome, and countries need assistance from the international community to deal with those constraints.
Countries took up the challenge of the Conference to adopt a reproductive health approach in many different ways, according to the report. Measures are being taken to broaden existing family planning, maternal and child health, birth spacing and/or safe motherhood programmes. In more than 30 countries, governments reported having begun a process of reorientation and re-examination of existing policies. Responding to the Programme of Action's call for promoting community participation in reproductive health care by decentralizing the management of public health programmes, several governments have taken steps towards decentralizing public health services to lower levels of administration.
Some countries worked to introduce more specific reproductive health services, such as the prevention and treatment of reproductive tract infections, as well as sexually transmitted diseases, the report states. In countries with less well-developed health services, the full integration of family planning into reproductive health programmes was expected to take much more time. In many of these countries, Governments introduced reproductive health services gradually within the primary health-care system.
The emphasis on a comprehensive reproductive health approach in population programmes has led to increased attention to the quality of care provided, the report goes on. The training of health-care providers and/or the revision of training materials seem to be standard components of most of the reproductive health-care projects developed in the countries responding after the Conference was held. Training aims to expand service coverage,
Population Commission - 17 - Press Release POP/609 2nd Meeting (PM) 26 February 1996
particularly in rural areas.
"Governments, often with the assistance of the international donor community, began to respond to the need to expand the availability of different contraceptive methods by increasing the method mix in health-care facilities", the report states. Projects have been formulated to introduce previously unavailable methods, while at the same time strengthening the general supply of contraceptives.
Although efforts are under way to improve the quality of reproductive health and related services, in the majority of developing countries responding to the inquiry, the full range of reproductive health services were either unavailable or inadequately available to all eligible women and men, according to the report. "Several reports mentioned that in most cases, most, if not all, components of the reproductive-health approach were available for middle- and higher-income groups in urban areas, whereas those services were not available or inadequately available to the majority of the urban and rural poor."
The report stresses that the international community considers generating greater public awareness, understanding and commitment to be vital for the successful implementation of reproductive health programmes. From information obtained from responses to the inquiry, it is clear that the Programme of Action has been widely disseminated. However, less than 50 per cent of the countries responding reported that the Programme of Action was translated into the national language. In addition to translate into the six official United Nations languages (Arabic, Chinese, English, French, Spanish and Russian) the Programme of Action has also been translated into Amharic, Bahasa Indonesia, Farsi, Mongolian and Vietnamese.
The survey indicated that the Conference triggered a process aimed at giving far greater attention than ever before to the needs and problems of adolescents in the field of sexual and reproductive health, the report continues. Nearly two thirds of the countries responding to the questionnaire reported having undertaken initiatives to address adolescents' reproductive rights and reproductive health and to put their needs in the political agenda. Often, governments and non-governmental organizations were working hand-in- hand to address adolescent reproductive health issues.
In countries where adolescent reproductive health issues were not being addressed, religious and/or cultural factors were most frequently mentioned as reasons for not addressing the reproductive health needs of this age group. Where governments were reluctant to address adolescent sexuality and reproductive health needs of adolescents, non-governmental organizations were filling the gap and undertaking activities for adolescents.
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Many countries now recognize the role of men as being important for an effective implementation of reproductive health programmes. Some countries reported using innovative interventions to involve them in issues related to reproductive and sexual health, family planning and their responsibility in these areas. One country reported that, in response to the finding that many women refused to practice family planning because their husbands prevented them from doing so, it was using male peer counsellors trained to convince married men to practice or support family planning.
The report highlights the important role played by non-governmental organizations in providing information and services to those segments of society not addressed by official governmental programmes, such as the poor, adolescents, commercial sex workers, unmarried couples and men, or by focusing on sensitive or controversial issues, such as traditional harmful practices against women, violence against women and abortion. The non-governmental sector has often been a front runner in innovative approaches to issues related to women's health, reproduction and family planning.
While a number of impressive initiatives are under way, the report states that many countries still face formidable obstacles or challenges which need to be addressed so that those countries can fully implement the recommendations in the Programme of Action. Socio-cultural factors, such as cultural and traditional values, were found to constrain the implementation of reproductive health programmes. Infrastructural constraints, such as the quality and skills of health professionals, were also often reported as constituting important obstacles. Limited financial resources for the health sector was also cited as a factor affecting those programmes.
Male opposition, often in combination with religious objections, was frequently given as a reason for the reluctance of governments to plan interventions. "Formal opposition or outright resistance from the religious hierarchy or establishment was a powerful factor in a number of countries." Sometimes, health-care providers were reluctant to address women's or adolescents' reproductive health needs.
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