Advancing Justice and Equity in Sexual and Reproductive Health and Care

Dr. Natalia Kanem, Executive Director, United Nations Population Fund (UNFPA), at the 9th Asia Pacific Conference on Reproductive and Sexual Health and Rights in Ha Long Bay, Viet Nam

Ladies and gentlemen,

Delegates, representatives of our host government, Viet Nam, whom we thank for their warmth and hospitality;

It is a genuine pleasure to be here with you today at the closing of the 9th Asia Pacific Conference on SRHR, in my capacity as the new Executive Director of United Nations Population Fund  – a responsibility I was privileged and honoured to assume following the untimely death of Dr. Babatunde Osotimehin earlier this year.

Thank you for your acknowledgment of Dr. Babatunde at the opening of the conference. He was a passionate advocate for the crucial issues we have been discussing here over the past several days –  the wide umbrella of sexual and reproductive health and rights covers issues that lie at the nexus of social norms, culture, religion, law and justice; and equity in their delivery and in receipt.

Much has been discussed at this important conference, yet I would like to talk to you about advancing justice and equity in SRHR from the perspective of UNFPA.  

I begin with "future-casting":

"What kind of future are we creating for Asia and the Pacific, and indeed for the world?"

We pose this question at a crucial time. The answer to that sweeping question, in large part, lies in how we care for the girls of today – in particular the more than 325 million girls aged 10 to 19 across this beautiful region.

Asia-Pacific – and the world – embarked on the 2030 Agenda for Sustainable Development, underpinned by the 17 Sustainable Development Goals. We seek to achieve a life of dignity for all, to truly leave no one behind.

At UNFPA, we are about to embark on a Strategic Plan to fulfill three transformational zero goals for our region and our world:

• Zero maternal deaths;
• Zero unmet need for family planning; and
• Zero gender-based violence and harmful practices.

All based on a platform of population data for development. These three goals are enshrined in the 2030 Agenda, as well as the Programme of Action that emerged from the 1994 International Conference on Population and Development. This continues to guide our work to shift policy from paper into action - work which is more relevant than ever.

It is said that "The moon moves slowly, yet it covers the town"

First, zero maternal deaths: In the past 50 years, the number of women dying from complications of pregnancy or childbirth has fallen nearly by half.

Yet still today, more than 300,000 women die globally each year, over 200 a day right here in the Asia-Pacific region. These deaths are tragic and preventable. Skilled birth attendance, with backup emergency obstetric care, is critical.

We applaud Viet Nam as a shining example for having reached MDG5 ahead of time.

But even before pregnancy and childbirth, every woman and girl should enjoy her right to freely decide when or whether to start a family and how many children she wants to bear.  Planning and spacing pregnancies are still key to reducing maternal deaths.

This leads us to Transformational Goal Number Two: Zero unmet need for family planning.

Some 214 million women want to avoid or delay childbearing. Why should they lack access to quality services and supplies, including modern contraception? Among them are 6.3 million sexually active adolescent girls in Asia and the Pacific. Without expression of rights and quality services for these precious girls, we will continue to have the estimated 3.6 million unsafe abortions among young women in this region every year. And we will see millions of new cases of sexually transmitted infections.

These combined epidemics have a profound impact: on the health and lives of children, adolescents and adults including causing fetal and neonatal deaths; cervical cancer; infertility; HIV risk; and physical, psychological and social consequences that can severely compromise the quality of life of those infected.

Economic factors are a major contributor to sexual and reproductive ill health. But so are patriarchal social norms often wrapped up in culture, including the taboos about discussing sexuality.

Meeting the diverse SRH needs of men and adolescent boys improves their health and SRH of their partners. Not leaving them behind is an effective way to promote sexual and reproductive health and rights for all.

UNFPA’s Transformational Goal Number Three: Zero violence and harmful practices against women and girls, is urgent and quite of the moment, very timely. The UN Foundation published my opinion piece on the movement today, #Metoo. 

First, let's consider sex ratio at birth. Globally, on average, 105 boys are born for every 100 girls – a natural sex ratio at birth. However, with the growing gender-biased sex selection, in some countries the sex ratio at birth now stands at about 120 boys to 100 girls – and in some sub-regions the number skyrockets to as high as 128 boys to 100 girls. 

More than 117 million women are “missing”, most of them in China and India — in a manifestation of persistent gender discrimination and son preference.

Second, the violence of child marriage and adolescent pregnancy, which jeopardize girls’ chances of achieving their potential. In developing countries – including in Asia-Pacific – one in three girls is married before age 18. One in nine is married under age 15.

5.4 million adolescent pregnancies occur every year, threatening the health and well-being of girls and of their children, truncating their life chances.

Sexually active unmarried adolescents and young people, should have the information and means to avoid pregnancy and unsafe abortion.

And then there is the ugly issue of gender-based violence. An estimated one in three women will experience some form of violence – physical, sexual, emotional – in her lifetime. In some parts of the Pacific and South Asia, the prevalence is far higher.

And yes, it is linked to patriarchal attitudes and norms that are perpetuated generation after generation.

Survivors of such violence can and do suffer sexual and reproductive health consequences – including forced and unwanted pregnancies, unsafe abortion, traumatic fistula, and sexually transmitted infections including HIV.

In Timor-Leste, almost one-quarter of all teenage girls are pregnant and having a baby by the time they are 20 years old. About 20 percent are married by the time they are 18. Even though premarital sex is supposedly ‘forbidden’, most teen pregnancies occur before marriage.

At one of our empowerment workshops for teen mothers in Timor-Leste, fielded by UNFPA with our partner Plan International, we met Lucia. She entered into a relationship with her much older teacher and much to her surprise got pregnant.  Lucia simply didn’t know anything about sex. Her family forced her to get married before the baby arrived,  in their words “to save the situation.”

Mostly Catholic Timor-Leste – like so many countries – actually has a comprehensive sexuality education curriculum. It is seldom taught. 

Many teachers are too embarrassed – some simply rip the pages out of the textbook entirely. Without access to information, let alone services or supplies, it’s not surprising that teen pregnancies are so high. Our programmes must give accurate, timely information young people are demanding.

In Bangladesh, largely conservative, Islamic, with a large youthful population, we have Generation Breakthrough, a project supported by UNFPA, to empower young girls and boys by teaching gender equality, respect for diversity and inclusiveness, and awareness of the patriarchal and religious norms that all too often impede the rights and well-being of women and girls.

Generation Breakthrough engages religious schools and clerics in imparting teachings, often using Koranic scripture to reiterate and strengthen lessons in gender equality and rights very positive results! 

17-year-old Mohammed recounted how his mother would give him the best pieces of fish, telling him that to take care of his parents in the future, he needed to sharpen his brain. His little sister got the leftovers.

Today, Mohammed is a Generation Breakthrough member fighting for gender equality, advocating that girls can do and be whatever boys can – a message reinforced by the local madrassa.  

The realization of sexual and reproductive health and rights is a human right, and an equity issue, a justice issue. Why should persons of diverse sexual orientation and gender identity be denied their rights, with their actions criminalized and their safety denied?

Stigma and discrimination in health-care settings, based on sex, race or ethnicity, mental health conditions, sexual orientation, gender identity, HIV status or nationality is unacceptable. It denies people their right to health. Moreover, whenever there is lack of respect for the rights of health workers, that affects their ability to provide services, and may be harmful to their own health. Governments are ultimately accountable for ensuring non-discrimination in health care.

The Asia-Pacific region has wonderful examples of community empowerment of sex workers, of people who inject drugs and people of diverse sexual orientation and gender identity.

The Aastha Parivaar sex workers’ collective in Mumbai, India brings together several community-based organizations to advocate for the health and legal rights of sex workers, including those living with HIV.  This has resulted in change at the local level that can be scaled-up at the national level.

The Asia-Pacific Coalition on Male Sexual Health, APCOM, based in Bangkok is a regional civil society partnership with the United Nations that advocates for the rights and well-being of men who have sex with men through the lens of HIV prevention and treatment.

These are just a few of the stories of challenge and opportunity that demonstrate how laws, social norms, culture and religion can influence the sexual and reproductive health and rights, equity and equality of billions of our fellow human being. Each is an example of perseverance. Of banding together in partnership. Of not ever giving in or giving up!

Because while economic inequality divides countries into haves and have-nots, inequalities in sexual and reproductive health and rights and gender inequality divide people into cans and can-nots.

A woman or adolescent girl who cannot enjoy her sexual and reproductive rights is one who cannot stay healthy, cannot complete her education, cannot find decent work outside the home and cannot chart her own economic future.

Inequality in sexual and reproductive health and rights disenfranchises untold millions of women. It also bolsters social and economic systems that enable a privileged few to rise to the top and stay there, while the vast majority fall to the bottom. Inequality robs individuals of their rights and denies whole nations the foundations for development.

So, coming back to my original question: What kind of future do we wish for Asia and the Pacific and what will it take to create it?

By 2030, the adolescent girls of today will form a significant proportion of the workforce – as leaders, innovators, teachers and more.  Many will also be mothers and caregivers for a new generation.  Let's not leave a single girl behind. Let each be equipped to craft her own future.
Imagine a girl standing at a fork in the road. [Project graphic.]

One path, she fulfills her potential – school and higher education; gainful employment free of sexual harassment; an adolescence where sexuality can be discussed without taboos; adult marriage or union to a partner of her choice, where sexuality can be enjoyed devoid of violence; healthy children if and when she chooses to have them; the ability to invest resources for the wellbeing of her children; and, ultimately, a secure old age. 

The other path adds to the risks she faces – child or early marriage; leaving school; early and unplanned pregnancies; unsafe childbirth; violence and abuse; HIV and other STIs; informal and erratic employment; a hostile home environment, possible displacement; and an insecure old age. If she is disabled, or a refugee that multiplies her vulnerability.

For adolescent girls to be a formidable force for good, they need support to overcome inequalities and discrimination on several fronts.

Our world is increasingly unequal. Let's not stop until we can change that! Change the power balance, create opportunities, and ensure rights, including the right to sexual and reproductive health.

Today's young people, 1.8 billion strong, make up a quarter of the world’s population. They are connected to each other and to the world around them as never before. They have needs and they have dreams that cannot wait.

Today’s young people are using technology and the world of instant communication to advocate for change and raise social awareness. I say to you, don't give up! The #MeToo movement is confronting widespread sexual harassment and abuse around the world, including right here in Asia and the Pacific. I say to you, persevere! Don't give up!

Also important, let's strengthen our ability to tackle the demographics of population ageing, already of concern for many countries in this region. Healthy ageing begins with healthy youth which begins with safe, planned pregnancy. That's the cycle of life, generation upon generation. 

For myself, my involvement with this region over two decades bring confidence and excitement for the upcoming two years of the ICPD+25.

You -- all the governments, all the civil society partners, the faith-based organizations and, especially, the young people gathered here today, will lead the region to come together to engage in open, frank and strategic dialogue. Let's work well together to cast aside harmful laws, norms and practices. Let's persevere to accelerate progress on sexual and reproductive health and rights for all.

Together, we can build a future where zero is the only acceptable number: zero maternal deaths, zero unmet demand for family planning, and zero violence and harmful practices against women and girls. Where we fulfill the hopes and dreams for a future for the Asia-Pacific region, and our world, where absolutely no one is left behind.

Never give up!

Thank you.