Reproductive Rights in the Post-2015 Development Framework: A critical element to making progress in addressing inequalities and eliminating poverty

November 6, 2012

DISCLAIMER: The findings, interpretations and conclusions expressed in this paper are those of the authors and do not necessarily reflect the policies or views of UN Women, UNICEF or the United Nations.

Abstract The Millennium Development Goals have not adequately addressed the grave social, economic, and gender inequalities across and within countries. In order to achieve greater development and fulfill human rights, it is necessary to formulate the post-2015 development framework so that countries can adequately reach the poorest and most vulnerable, by addressing the structural inequalities that exacerbate poverty and aggravate multiple forms of discrimination. This paper will look at the ways in which the respect, protection and fulfillment of reproductive rights can positively impact a whole range of development outcomes and reduce multiple inequalities. It also proposes that the next development agenda be designed within a strong gender and human rights framework, and that special consideration be placed on creating a goal that captures progress on ensuring womens reproductive rights. Note on the authors and acknowledgements Grupo de de Informacin en Reproduccin Elegida (Information Group on Reproductive Choice, GIRE) is a non-profit, non-governmental organization founded in 1991. Our mission is to promote and defend womens reproductive rights, within the context of human rights. Our vision as an organization is to be a reference on the topic of reproductive rights for decision makers, opinion leaders, and legal and health professionals. We aim to provide a solid model of political advocacy for Mexican and Latin American civil society organizations and to continue to be a reference for strategic litigation in cases of reproductive rights violations. Since its founding, GIRE has set out to collect, organize, and distribute information on reproductive rights. We work so that all Mexicans can exercise their right to decide on issues related to their reproduction. Our work is focused on promoting legal reform and changes in public policy that increase and guarantee access to reproductive health

services and the exercising of reproductive rights, within a human rights framework. GIREs work is primarily directed toward decision makers, officials in the three branches of government, legal and administration of justice professionals, health providers, the media, opinion leaders, academics, civil society organizations and the general public.

GIRE would like to thank the United Nations Population Fund (UNFPA) for the financial and technical support provided in the formulation of this paper.

I. Introduction The International Conference on Population and Developments Program of Action, agreed to by 179 governments in Cairo in 1994, created a paradigm shift in health and population policy. The changes consisted of moving away from the provision of narrow family planning programs used to control womens fertility through target and incentive schemes, to an understanding that population growth could be stabilized by empowering women, promoting and protecting their reproductive rights, and providing them with the sexual and reproductive health information and services that they need. The Program of Action created a blueprint for development and population programs taking into account the interdependence of sustainable development, human rights and gender equality in the fight against global poverty. By achieving gender equality and womens empowerment, guaranteeing universal access to integrated sexual and reproductive health services, respecting womens reproductive rights, and addressing economic and environmental patterns of consumption and production, governments can reach sustainable development.

Although the Cairo Program of Action served as a blueprint for the Millennium Development Goals (all goals were previously included in Cairo), reproductive rights were excluded from the Millennium Declaration adopted in the year 2000. The Cairo goal to achieve universal access to reproductive health was reduced to improving maternal health under MDG5 and was not added until seven years later. But improving

womens health during pregnancy and childbirth cannot be done without guaranteeing womens reproductive rights, providing women with the comprehensive health services that they need, and addressing the structural gender, social and economic inequalities that place women at risk during this period. Although MDG3 does seek to promote gender equality and the empowerment of women, it is focused on a narrow set of targets (around education, employment, and political participation).

In 2007 a new target on universal access to reproductive health was added to the MDG framework. This was an improvement but still insufficient to cover the full breadth of reproductive rights and gender equality. This target is narrowly conceived to reflect progress in the supply of contraceptives and it ignores the multiple barriers that women face in accessing them. Furthermore, it overlooks womens needs to have multiple contraceptive choices available to them in order to safely regulate and control their fertility and to access a comprehensive package of quality health care services that are available, accessible, affordable, and acceptable to them. Moreover, this target neglects the need, especially for adolescents, to receive comprehensive sexuality education and information on sexual and reproductive health that is vital to ensuring reproductive rights. Finally, it overlooks the need to address structural socio-economic and cultural factors, such as unequal power relations between men and women that are entrenched in cultural practices, as well as the feminization of poverty , that increases the vulnerability of girls and women to violations of their human rights and contributes to perpetuate gender inequalities.

Learning from the experiences of countries in implementing both Cairo Goals and the MDGs is essential to conceptualizing the next development framework. Further, a clear gender and human rights perspective, with particular attention paid to equity, must be taken in this analysis if we are to collectively ensure that the poorest and most marginalized have their needs met and their rights fulfilled. Critical to these efforts are

securing womens bodily autonomy: for women to have control over their sexuality and reproduction.

II. Measuring progress on reducing inequalities through ensuring girls and womens reproductive rights

Violations of reproductive rights include all of those practices and manifestations by any individual or institution that seeks to exert control over womens bodily autonomy. In international human rights law, violations of womens reproductive rights constitute violations of human rights, including the right to information, the right to life, to nondiscrimination, to health, and to be free from torture, cruel or inhuman treatment. This primacy of international law therefore imposes an obligation on States to protect, respect, and fulfill these through all means necessary. Reproductive rights violations lead to negative development outcomes because they fuel gender, economic and social inequalities. These violations include preventable maternal mortality and morbidity; forced sterilizations and forced abortions performed on women belonging to different ethnic minorities and also on those who are HIV positive; lack of effective access to safe abortions where legal due to non-regulation of conscientious objection, among other factors; lack of informed consent and choice over contraceptive methods; harmful practices such as honor killings, female genital mutilation, and early and forced marriage; and sexual violence, among others.

Womens oppression and lack of agency denies their human dignity and places them in situations where they are powerless to prevent violent situations and to claim their right to be treated with respect in their homes and in accessing services. Furthermore, it limits their freedom to acquire knowledge about their bodies and their rights. For these reasons alone, the international community has a moral imperative to secure womens reproductive rights. This can be done by measuring the effectiveness, reach and quality of womens health care programs, but also necessitates participatory and social

accountability approaches so that women are able to influence those areas requiring political, social and financial investments .

Two main components of reproductive rights, particularly sexual and reproductive health, are explicitly embedded in the MDGs: improving maternal health and combating the spread of HIV/AIDS. In the United Nations Report of 2010, it was made evident that MDG5, improving Maternal Health, is the goal that is most lagging behind.1 It is a neglected goal in that until fairly recently there has been little political will and inadequate financial resources at the country level to improve the laws and policies, cultural practices, and health care services that are needed to meet its first targetcutting the rate of womens death during pregnancy and childbirth by 75%. Global estimates point to nearly 287,000 women dying each year due to preventable causes during pregnancy and childbirth and between 10 and 15 million more suffering from serious health complications (WHO, 2012). (WHO, 2012). Further, MDG 5b- achieving universal access to reproductive health by 2015, is the most off-track (UN, 2010). Moreover, reaching adolescent girls and young women with critical HIV prevention efforts are also failing, evidenced by the fact that globally, young women aged 15-24, are most vulnerable to HIV with infection rates twice as high as in young men, and accounting for 22% of all new HIV infections (UNAIDS, 2011).

Measuring progress on the attainment of womens reproductive rights, including how women carry a wanted pregnancy to term and deliver it safely, is challenging because death and disability during pregnancy and childbirth is still considered inevitable and highly normalized in many societies and cultures. The modest value that is placed on poor womens lives leads to little investment by governments, communities, and health care providers in creating the conditions necessary to avert these deaths and disabilities. Maternal deaths are the result of combining poverty, social exclusion and
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Estimates from 2010, 2011 and 2012 declare that only thirteen countries are on track to meet MDG 5 by 2015 and only nine were likely to meet MDGs 4 and 5. Lozano R et all, Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis 378 Lancet 1139.

gender discrimination. The chief causes are often hemorrhage, obstructed labor, sepsis and eclampsia and unsafe abortion ((13% of cases according to WHO, 2012), but they also have to do with poor nutrition, anaemia, early marriage and child-bearing, violence and low female educational attainment (Sen, 2009). Addressing all of these requires strengthening health systems, particularly primary health care that can provide women with comprehensive sexual and reproductive health services: contraceptives of their choice, HIV prevention (and treatment in high burden countries), and maternity care (antenatal care, skilled birth attendance, emergency obstetric care). It also means training health providers to be sensitive to the needs of poor women (OHCHR, 2010). As Sen states, getting treatment is not helpful unless it is effective, but effectiveness is only partly determined by such things as the qualifications and knowledge of the provider. The other part is governed by the extent of the gender, caste and economic class chasm between providers and patients. Perfectly well-trained providers let women die or provide poor quality care that can result in long-term morbidity and disability because of the yawning gap between us and them (Sen, 2009).

Moreover, many women who die in pregnancy and childbirth do so at home and will not access a healthcare facility because these are too difficult to reach, unaffordable, or culturally inappropriate. In order to reach these women, countries must conduct needs assessments of the health workforce and train community health workers with midwifery skills, particularly in rural areas, to attend to these women close to where they live.

As Yamin and Falb have articulated, progress on MDG 5 is particularly difficult to assess because of the initial design of the MDGs themselves (global aspirations not meant to become national planning targets), the design of the target (arbitrary and inappropriate); and the lack of country ownership and accountability in measuring progress. Further, those countries with the highest rates of maternal deaths have not

been supported to strengthen their civil registration systems or to provide proper training to those registering maternal deaths (Yamin and Falb, 2012).

The measurement of maternal deaths has been incredibly difficult, due to weak registry systems that do not provide for accurate and reliable information on the causes of death. In addition, the indicators were designed to measure quantitative progress focused on lowering the ratio of maternal deaths through increasing maternity care services (MDG5 Target 5A), and achieving universal access to reproductive health through increasing the contraceptive prevalence rate (MDG5 Target 5b). These indicators are inappropriate and inadequate because they do not capture the gender, income, social, ethnic and various other types of inequalities that are so necessary to address in order to improve womens health.

Yamin and others have long advocated for having an indicator that completes the reproductive health picture (adding on to the provision of contraception, antenatal care, and skilled birth attendance) through measuring the availability and use of emergency obstetric care (EmOC). Providing EmOC through health facilities that treat emergency obstetric complications is indeed critical to saving womens lives during childbirth. Measuring the provision of this service can also serve as a basis for asking questions about the availability, accessibility and quality of EmOC, whether women are using the service, and which women are using them- (disaggregated data by socio-economic status, age, ethnicity, place of residence, etc). Similarly, a 2012 Lancet study found that the unequal distribution and use of Skilled Birth Attendance Services in rural areas and among the poorest quintile was a main driver in explaining maternal health outcome inequalities (Barros et al, 2012).

Having this type of process indicators would be fundamental in measuring inequalities from a reproductive rights perspective in so far as we are talking about women who are pregnant and accessing a health care facility. But a reproductive rights approach also

underscores the structural and legal barriers, as well as gender and economic inequalities, that keep women from accessing or using this information and services. This could be done by including measurements such as prevalence of intimate partner violence, developing indicators that measure unequal power relations within a given population group, using quality of care indicators that point to addressing the discrimination by health care providers, and measuring the impact of laws and policies that create enabling environments or which restrict them, for the realization of sexual and reproductive rights, such as those that require spousal or parental consent, user fees in health care services, or lack of sexuality education and life skills, among others.

Moreover, current MDG indicators do not capture womens intentions to manage their fertility safely and effectively because they do not take their sexual and reproductive preferences and intentions into account. Instead, a womens reproductive health indicator that also tackles inequalities in access to health care must measure access to safe services for the voluntary termination of an unwanted pregnancy. This represents the ultimate measure of safe and effective fertility regulation in accordance with womens reproductive intentions (Dixon and Germain, 2006).

In addition, analyzing demographic and health surveys as the only tools to measure sexual and reproductive health and rights is insufficient, because these are often not good measures of social progress nor do they capture inequalities within reproductive health. Developing process indicators and qualitative targets that do reflect womens reproductive rights must make sure they include the young and unmarried; data on abortion (safe or unsafe); and that they assess the social and cultural context on decision-making- including the ways in which these shape gender and power relations that affect reproductive decisions.

The development of monitoring systems for complying with womens reproductive health and rights in the post-2015 agenda must also include human rights accountability

mechanisms with multiple forms of review and oversight as established by the Office of the High Commissioner for Human Rights Technical guidance on a human rights-based approach to maternal mortality and morbidity. These are ensuring administrative accountability, social accountability, political accountability, and national legal accountability, as well as with multiple actors at various levels: professional; institutional; health system; private sector; and donor accountability (OHCHR, 2012).

But even with all of the necessary services being provided, adequate financing on health, efficient management, logistics and staffing in public systems, accountability mechanisms in place, and the removal of user fees - the transformational change that will lead to reproductive rights and womens health becoming a reality is ending genderbased discrimination. There is no technical fix for achieving such a transformation in gender power relations. Rather, it requires activism, campaigning, and accountability by communities who demand that womens reproductive rights be ensured. This means sustained investment in grassroots organizing that creates awareness at the individual and community levels and eventually becomes a social transformation that does not tolerate, under any circumstances, any violence against girls and women, including in relation to their sexual and reproductive health. III. Filling the gaps and moving forward In the Post-2015 MDG framework, the link between ensuring womens reproductive rights and achieving gender equality as development progress must be made. This entails guaranteeing womens reproductive rights as one of the surest and most effective ways to promote equitable and sustainable development. In particular, the next development framework must not repeat the mistakes that were made fifteen years ago and in this way ensure that:

a. The development framework is firmly embedded in the principles of equity, gender equality, participation and accountability.

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b. There is a gender perspective and a human rights based approach applied to developing a global framework of development goals. c. There is a set of targets and indicators developed for national and sub-national levels. d. There is a specific goal on achieving equitable and universal access to sexual and reproductive rights and health. e. Womens and young peoples sexual and reproductive rights are met throughout the entire framework (mainstreamed). f. There are effective and applicable monitoring and accountability frameworks embedded in measuring progress for the achievement of a next set of goals.

The development of such a framework that includes reproductive rights should tackle and reflect the underlying and structural barriers that women face in reproductive and sexual decision-making. One of the process indicators related to such barriers could be, for example, to achieve equitable and universal education on human sexuality that is measured by curricula that encourage girls and boys to challenge gender norms, that gives accurate information about sexuality and sexual and reproductive health, and enables them to claim their human rights, gives them the skills to negotiate relationships, stay healthy, and make informed decisions about their future (UNESCO 2010).

Including a stand-alone goal that seeks to guarantee reproductive rights as well as having a reproductive rights perspective mainstreamed throughout the next development framework is essential to meet the current MDGs, as well as any future iteration of them. If we look at the current MDG framework, securing reproductive rights is vital to the achievement of each goal because: Womens control over their own fertility contributes to the reduction of poverty. Having the number of children they desire - often fewer children, with more time between their births, enables women and families to invest more in each childs education, food and health. (MDG1)

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Progress on universal and equitable primary and secondary education requires that parents have the means to be able to send their children to school in the first place. When women decide to have smaller families, they spend more money per child. This is especially important for girls whose education is often sacrificed when resources are limited. (MDG2)

Only when women make free and informed choices about sex and reproduction can gender equality and womens empowerment be achieved. The right to make decisions and to access information and services related to sexual relationships, marriage, pregnancy and childbirth- free of coercion, violence and discrimination- is fundamental to womens equality and for their ability to participate in social, economic and political land therefore contribute further to the sustainable development of their communities and countries. (MDG3)

Child survival and development cannot be achieved without safeguarding womens human rights first and foremost- this includes their ability to access adequate nutrition and nutritional supplements while pregnant and increased access to maternity care (prenatal care, skilled birth attendance and emergency obstetric care), and improved access to prevent vertical transmission of HIV (CRR, 2012). (MDG4)

Improving maternal health cannot be achieved without guaranteeing womens reproductive rights. Ensuring that women have access to adequate information about their reproductive health and access to quality sexual and reproductive health care are vital. Maternal mortality and morbidity can be significantly abated by ensuring women receive care before and during pregnancy, delivery, and after childbirth. Further, prevention of unwanted pregnancies can limit the high incidence of unsafe abortions and reduce maternal deaths. Finally, addressing the underlying social conditions that can contribute to high-risk pregnancies is essential for improving maternal

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health. This includes interventions to address intimate partner violence (CRR, 2012). (MDG5) In order to halt the spread of HIV and achieve universal access to HIV treatment, women must be able to access integrated sexual and reproductive health services, including voluntary counseling and testing of HIV and other STIs, contraceptives, and comprehensive sexuality education to negotiate safer sex and prevent HIV. (MDG6) Achieving environmental sustainability requires analyzing population dynamics for development planning. This entails securing womens reproductive rights in rapidly urbanizing populations and reaching women with adequate reproductive health care in rural areas, including family planning and maternity care services closer to where they live. When women control their fertility and reproduction, they are better able to make responsible decisions about their environment and their communities. (MDG7)

In designing the successors to the MDGs and in order to guarantee womens reproductive rights, the structural causes of reproductive ill health must be addressed. This includes careful consideration to how the development of process indicators is conducted so that they seek to assess the socio-cultural context of individual decisionmaking, including the ways in which these shape gender and power relations that affect sexual and reproductive decisions.

A reproductive rights approach to development requires creating the enabling environments for girls and women and other marginalized communities to know their bodies and their rights, have the skills to negotiate sexual relationships, avoid violence, unwanted pregnancies, HIV, and early marriage. It also necessitates eliminating income inequalities in accessing reproductive health care by eliminating user fees and providing them with free counseling, contraception, maternity care and child health services.

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Privatization in health care is one of the issues that will perpetuate economic inequalities and also undermine the fulfillment of the right to health. Studies from middle-income countries such as Poland, China, Indonesia and Pakistan2 illustrate how privatization has not strengthened health systems and is rather exacerbating income inequalities in the delivery of health care due to the inability to reach the poorest and most vulnerable, who have the highest burden of disease, with the services that they need due to lack of purchasing power, inaccessible residential locations, and inadequate health literacy (Berer, 2010). Moreover, there is no guarantee that private health services are of quality or sufficient to meet the health care needs of the poor. The conditions of clinics- both private and public- especially in regards to reproductive health care are appalling in much of Sub-Saharan Africa and Asia. The failure of governments to institute quality of care regulations, train, deploy and to equip health care providers with the adequate skills and supplies that they need, are some of the many challenges that need to be addressed in order to close the gaps in inequalities while accessing health care and fulfilling womens reproductive rights.

The ICPD Program of Action states that the provision of reproductive health care should not be confined to the public sector (para 7.26 PoA). However, the private delivery of health services does not mean that the State should give away its role as the main duty bearer. Governments have the obligations to respect, protect and fulfill the human right to health. While governments are expected to use the maximum available resources to meet this right as per the obligation of progressive realization, the fact is that user fees and the inexistence of implementable health standards across and within countries leaves poor people, and particularly poor women, with little recourse to enjoy this
2 See Ravindran, S: Privatisation in reproductive health services in Pakistan: three case studies RHM 18 (36) 13-24, Nov 2010; Gao, Yu et al.: Barriers to increasing hospital birth rates in rural Shanxi Province, China RHM 18 (36) 35-45, Nov 2010; Mishtal, J: Neoliberal reforms and privatisation of reproductive health services in post-socialist Poland RHM (36) 56-66, Nov 2010; Sciortino, R et al: Caught between social and market considerations: a case study of Muhammadiyah charitable health services RHM 18 (36) 25-34, Nov 2010.

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human right. In order to have greater development outcomes that are pro-poor, and to reduce social, economic and gender inequalities in accessing reproductive health care, it is the obligation of governments and health care providers to ensure that there are sufficient human, technical and infrastructure resources required for providing skilled and quality care; that there is equity in access to services; and that effective and efficient service delivery is in place (Keith-Brown, 2004). Further, it is necessary for civil society organizations to monitor government budgets and demand greater transparency and accountability in the use of resources for health care, implementation of programs, and delivery of services.

There are several actors and governments that are keen to focus discussions within the Post-2015 development framework on the provision of universal health coverage. Universal health coverage refers to financing of health services through the provision of health insurance. It does not ensure standards of care or ethics in providing care, nor does it necessarily prevent providers from charging user fees. Therefore, we cannot say that universal health coverage ensures access to health services, or for that matter, reproductive health services. While Universal Health Coverage schemes has increased access to generic medicines in public health centers in India and Thailand, for example, it has not managed to provide people with comprehensive, preventive or quality reproductive health care. This is an obvious economic inequality, which also has gender implications. Universal health coverage does not assure that the underlying determinants of health will be addressed, such as adequate transportation, housing, sanitation, nutrition, or other infrastructural and environmental needs that are essential to ensure peoples access to sexual and reproductive health services as well as all primary health care. Any attempt to institute universal health coverage as a principal strategy for instituting global development priorities post-2015 must strive for achieving universal health care and include:

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1. The provision of quality, comprehensive, integrated sexual and reproductive health services, counseling and information for women and adolescent girls, with respect for their human rights, and with an emphasis on equality, equity and respect for diversity. As defined by the ICPD PoA in 7.6 and 8,25, comprehensive services include all forms of safe and effective contraception, safe abortion where legal and post abortion care, maternity care, prevention and timely diagnosis and treatment of sexually transmitted infections including HIV, breast and reproductive cancers, and infertility. Ideally, these should be integrated, onestop services tailored to womens needs throughout the life cycle, with effective referral. 2. The elimination of all user fees for maternal and child health services for the poorest women. 3. The respect for girls and womens human rights, including by ensuring their confidentiality, privacy and autonomy in all decisions related to their sexual and reproductive lives (particularly from health care providers). 4. The principles of availability, acceptability, accessibility and quality in fulfilling the right to health. This includes developing protocols and training providers to meet the needs of diverse populations, including through paying particular attention to the needs, lesbian, gay, bisexual and transgender populations, and people living with HIV, sex workers, among others.

V. Parameters and Considerations for a Future Development Framework beyond 2015

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Today, there are 1.8 billion young people between the ages of 1024 who do not have access to the comprehensive sexual and reproductive health services and sexuality education that they need for a safe and healthy life. More than 215 million women who are married or living in unions do not want to be pregnant but lack access to modern contraception, and even more lack access to other vital sexual and reproductive health services and information. The prevalence of anemia due to poor nutrition, continuing lack of safe drinking water and basic sanitation, and the health impacts of rising global and national inequality place the sexual and reproductive health of girls and women at grave risk. Too many women and girls continue to face gender inequality, violence, and other violations of their human rights. In order to change this picture, it is imperative that the successor to the Millennium Development Goals place womens reproductive rights at its center.

The next development framework must be firmly rooted in human rights standards and principles of participation, accountability and equality and non discrimination, including gender equality, and prioritize the elimination of gender-based discrimination for the achievement of gender equality and womens empowerment.

The application of human rights principles and of gender equality norms entail the creation of enabling environments necessary for girls and women to be empowered, and be able to access health services, economic livelihoods, and education opportunities. Further, it is essential that governments develop adequate monitoring and accountability mechanisms that evaluate progress in closing the gaps among different inequalities, towards greater social justice and not merely the achievement of numeric targets.

Addressing gender and economic inequalities also requires developing ways of understanding reproductive health-seeking behavior by designing methodologies that

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can help explain cultural meanings attached to sexuality, power relations, and the negotiation of sexual relations and fertility decisions. The Cairo Program of Action mandates social, economic and political initiatives at the national level to create an enabling environment for the attainment of sexual and reproductive health and reproductive rights. The multiple benefits of investing in securing reproductive rights and health include improvements in girls education, womens empowerment, and political participation.

In order for the post-2015 development framework to be successful, there needs to be country ownership and flexibility in how each national government implements it. Through a human rights-based approach, governments should be able to develop adequate policies, programs and budget accordingly, with realistic, yet ambitious, targets that they can adequately strive for and meet. It is fundamental for governments to assess their national AIDS, maternal and child health, and broader sexual and reproductive health plans and programs in order to identify gaps and devise strategies for reaching those populations that need these services the most, closer to where they live, and with respect for their human rights. The following parameters are suggested for designing a development framework that respect reproductive rights:

1. Situate the development goals within a strong gender analysis in full alignment with human rights obligations. Ask questions about how the achievement of the goal(s) require(s) different investments in women than in men,- including in the poorest and most marginalized women- and develop differentiated targets and indicators, accordingly. 2. When developing a health goal, prioritize a package of comprehensive sexual and reproductive health services and put particular attention to developing corresponding process indicators disaggregated on different grounds (sex, sexual orientation or gender identity, age- by five year cohorts, ethnicity, disability, place of residence, HIV status, socioeconomic status, or other) in order to better measure

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health inequalities. Indicators should be context-specific, results-based, quantitative and qualitative. 3. Create monitoring and accountability mechanisms for each of the goals that enables community participation at all levels and creates spaces for dialogue and reflection in measuring progress.

Additional targets with process, outcome and structure indicators must be built into a development framework that prioritizes womens reproductive rights. These could include the following: The proportions of all births that are unwanted The context for sexual initiation and first marriage (consensual or forced) Contraceptive choice and unmet need for spacing and limiting births Contraceptive use among married and unmarried adolescents Pregnancy and abortion rates for adolescents Legal status and safety of abortion services Estimated prevalence of sexually transmitted infections, including HIV among females and males differentially Estimated incidence of intimate partner violence Prevalence of early and forced marriage.

VI. Conclusions Health and development policies that are based on equity and have a gender and human rights perspective are critical to address inequalities. The provision of an essential package of sexual and reproductive health services free of charge and free of violence, discrimination and coercion in low and middle income countries will attend to the poorest and most vulnerable as well as ensure their rights. Finally, the focus on community involvement, participation and accountability are essential to achieve greater development outcomes and create healthier and more just societies.

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