Considering the giddy sense of optimism that followed the 1990s international conferences (World Conference on Human Rights, 1993; International Conference on Population and Development, 1994; World Conference on Women, 1995; World Summit for Social Development, 1995), it is easy to feel dispirited by the roll back in progress toward sexual and reproductive health. There are areas, however, where we should be celebrating, particularly when we think of the continued energy with which many in the international community are fighting to keep sexual and reproductive health and rights on the international agenda. Women's groups have always been at the forefront of this fight, but there are others, including national governments, who want to ensure that the promises made in Cairo are realized without interference.
The International Conference on Population and Development (ICPD), held in Cairo in 1994, was a nine-day conference that addressed a number of important, and often controversial, issues including abortion, immigration policy, sexual and reproductive health and rights, combating HIV/AIDS, protecting the health of adolescents, the empowerment of women, urbanization and access to health care. By the end of the conference, delegates had agreed to a 16-chapter Programme of Action that set out a series of recommended actions on population and development.
The consensus document agreed to during the ICPD, now commonly referred to as the 'Cairo consensus', reflected something of a shift in the way policy makers had been addressing population concerns to that point. Concerns over rapid population growth had driven many of the national and international family planning programmes for a number of decades prior to the conference. These programmes had often relied on measures such as forced sterilization and other abusive practices. In Cairo, there was greater attention paid to people-centred, rights approaches to family planning.
This edition of Development sets out to map what has changed since the Cairo consensus was reached. In determining where all the pieces of the puzzle fit, we wanted to be able to signal where we may have more work to do, where we need to maintain gains and where we need to be on our guard. The authors have described the texture of some of the many debates that continue to flourish and some of the new debates only beginning.
The promise of Cairo
During the 1994 ICPD, the Cairo consensus document emerged largely as a result of intense lobbying on the part of women's health activists from around the world. The document highlighted the importance of women's empowerment (mostly through increased educational attainment) and of the need for higher quality of care in health services and the attainment of sexual and reproductive rights.
Many of those who were in Cairo and who examined its implications afterwards felt that the agreement in Cairo was not entirely satisfactory. Some feminists, both Northern and Southern, opted out because the idea of women's empowerment was too narrowly focused on education and because reproductive health and quality of care were only viewed as important in as much as they related to raising contraceptive prevalence rates. In other words, despite the uneasy agreement in Cairo, there was a feeling that reproductive and sexual health and rights were on the agenda only to reduce fertility.
Despite these misgivings, the 1994 ICPD Programme of Action did create a framework for the universal realization of reproductive and sexual health and rights. Governments were persuaded to reject coercive population control policies that had gained ground in the 1970s and 1980s in favour of a new approach aimed at meeting the needs of individual women to access a wide array of reproductive health services. At the time, the gains made were far beyond what many imagined in terms of their recognition of the importance of reproductive health to sustainable development and the notion that women and men had a right to decide freely about their reproduction and sexuality. These gains seem even more astounding in today's chilly political climate and women are fighting hard to maintain the new status quo.
These advances also need to be viewed in the context of three other important conferences that took place in the 1990s and that furthered women's rights in the area of sexual and reproductive health.
At the 1993 Vienna Conference on Human Rights, women succeeded for the first time in affirming that 'women's rights are human rights'. It was accepted that human rights are to be enjoyed in both the public and private spheres and, therefore, need to be promoted in both spaces. As a result, rape, domestic violence and reproductive health were added to the human rights agenda. At the World Social Summit in Copenhagen in 1995, nations committed themselves to a formula that would ensure that all people were provided with at least the very basic human development services, including equitable access to health, education and financial assets.
Finally, the Fourth World Conference on Women, held in Beijing in 1995, went further than Cairo in broadening the very notion of reproductive rights. Where the Cairo Programme of Action had included reproductive health as a part of the family planning agenda, Beijing stressed reproductive health in the context of women's whole lives. As such, the Beijing Platform for Action set out a comprehensive plan to set health in the context of the wider social, political and economic reality in which women live.
Women's groups rightly felt that they had shifted the political landscape from 1993 to 1995. The question now is what does the world look like since the conferences? Did their increasingly progressive agendas on sexual and reproductive health and rights make a difference?
A failure for women?
By many practical indicators, there have been advances in access to family planning, access to skilled birth attendants, increased education for girls and many positive legislative and policy changes that support women. The challenge remains great, however: unacceptably high levels of maternal mortality mean that about 530,000 women die each year of pregnancy and childbirth related causes, 99 per cent of these in the developing world. Indeed, maternal mortality is the leading cause of death for women of reproductive age in developing countries (WHO, 2004).
The failure of the world to address the pressing issue of maternal mortality raises some interesting questions about sexual and reproductive health and the priority given to it. The Cairo conference did mark a conceptual shift in thinking around sexual and reproductive health and rights and there has been the appearance of increased political commitment to the issue. The question remains how to translate these commitments into actual positive changes for women's lives. In the meantime, we need to continue to celebrate and reaffirm the progress that was made in Cairo.
The next question is how to continue to move the agenda forward. What are some of the areas where the world community can create spaces for greater shifts in progress towards sexual and reproductive health and rights?
Engaging in the Millennium Development Goals (MDGs)
One of the greatest debates on gender equity of this decade surrounds the exclusion of sexual and reproductive health from the MDGs. Despite widespread international recognition, and the best efforts by many progressive governments, neither the MDGs nor their associated targets include specific mention of reproductive and sexual health and rights. This absence was largely due to the opposition from a minority of conservative governments, including that of the United States and some Islamic and Catholic countries.
With the upcoming five-year review of the Millennium Summit, there have been renewed discussions to ensure that reproductive and sexual health and rights are recognized as critical components. The Millennium Project report by Jeffrey Sachs and the UN Secretary General's report on the MDGs, both underscored the need to tackle the unacceptably high rates of poor reproductive health in many developing countries if we are to address the broader challenges of poverty reduction and sustainable development (UN, 2005; UN Millennium Project, 2005). UN agencies, governments and non-government organizations have been discussing the possibility of establishing either a target or an indicator on reproductive health within the MDG framework. Opposition continues to come from more conservative governments.
These debates are occurring in a very different climate from the ICPD discussion where the question of abortion as a public health question was openly addressed. Today, no government has attempted to put abortion on the table during the Millennium process since the political climate is such that any such attempts would be fruitless. Even the most supportive governments fear that opening up the MDG agenda is risky and therefore also oppose the inclusion of new targets on sexual and reproductive health.
For many, the ICPD goal of universal access to reproductive health by 2015 is considered a useful target since there are well-established monitoring and reporting mechanisms already in place. There has been strong support from developing countries, many of which were formerly opposed to supporting sexual and reproductive health and rights, and many are devoting their own funds to the priority. This support marks a significant and encouraging change in the political landscape.
While the MDG process suffered many flaws, it does offer another possible space for advocacy on the issue of gender equality and sexual and reproductive health and rights. The UN itself is currently under attack from fundamentalist forces, yet remains an important forum for progress on sexual and reproductive health and rights. Some of the real progress will happen at the national level where governments will determine their own implementation plans for the MDGs. Continuing to use the MDG process therefore represents an important opportunity to reframe the discussion and move forward constructively with this agenda.
Ensuring a rights-based approach
Since Cairo's redefinition of the understanding of sexual and reproductive health as an issue of rights, there has also been another interesting evolution. Starting from the idea of rights, practical questions have been raised among reproductive and sexual health practitioners in how to use a rights-based approach to shift their programming.
What does it mean to integrate a rights-based approach to programming? Practitioners are using human rights values and principles to focus attention on the underlying power dynamics that are reflected in women's access to reproductive health services, and so determine appropriate interventions including reallocating resources, challenges hierarchies and so on (Hawkins et al., 2005: 4). The main innovation in programming involves looking beyond the health sector to achieve advances. This kind of programming can involve advocacy at the level of community and women's groups and work to increase the capacity of governments and service providers to provide high-quality services.
For example, in Bolivia a community outreach programme focused on health and domestic violence has had a significant impact on women's lives. The Gregoria Apasa Women's Centre in La Paz is a network of 17 local institutions offering a wide range of services from health care to skills training to shelter for battered women and their children. The Centre, funded in part by CIDA's Gender Equality Fund, offers legal assistance and accompaniment to women pursuing cases through the legal system. It runs a prevention programme of awareness raising and training courses in human rights, family law and women's rights. Human rights trainers' organize workshops in their neighbourhoods for women who want to work as volunteer 'defensoras' or human rights advocates. They also give courses to police, women's shelter operators, health-care workers, judges and other social sector workers. By understanding the complex context of women's lives and working to ensure that services are provided and rights are respected, the project is an example of rights-based programming that support the needs of women (CIDA, 2005).
The increase in rights-based programming is a sign of the maturing of the debate since Cairo. In particular, there is broader recognition of the fundamental importance of reproductive rights to women's empowerment. The growth of the rights-based approach in development programming is particularly noteworthy: it identifies reproductive and sexual health as a human rights issue deserving of increased visibility and urgency (Outlook, 2003: 3). Given the cool climate for rights discourse in the international community, this re-framing of the challenge represents another way forward.
Avoiding a feminist fundamentalism
In looking at the debates around Cairo there remains a hint of a dated feminist dilemma around strategic versus practical needs. Are some of the practical decisions that we made as a movement now coming back to haunt us: a feminist 'blow-back' of sorts?
We need to recall that feminism could also be viewed as a fundamentalism if it prevents us from talking more deeply about entrenched ideas. In the case of abortion, for example, we still have difficulty melding the lived experiences of women who have had abortions and miscarriages with our discourse on choice and the definitions surrounding the meaning of the foetus.
In 2003, I conducted some preliminary background research for a documentary film on women's experience of miscarriage and abortion. The personal testimonials provided a picture of the feeling of alienation that many of the women, most of whom were Northern feminists, felt being unable to express their sometimes conflicted feelings because of the constraints imposed by the political struggles. Many felt that their loss and grief were not respected because to do so would change the dynamics of the debate around abortion.
While still tied to the problematic concept of 'choice,' some feminists have also actively sought to limit sex selective abortion while turning away from the struggle by many in the disability rights community who oppose selection based on disability. Disability and gender are both social constructs, yet selection based on disability is seen as a question of women's choice while sex selection is treated differently (see the paper in this issue by Gregor Wolbring).
When it comes to questions of prostitution, sex work and pornography, there has also been considerable difficulty in having these honest and open discussions.
Discussion on many of the topics related to sexual and reproductive rights are constrained both by entrenched beliefs and well-founded fears of losing hard-won gains. Avoiding fundamentalism in our own thinking will permit us to continue the process of collective learning.
Focusing on both economic justice and sexual and reproductive health and rights
At the 49th session of the Commission on the Status of Women (Beijing+10), the US introduced a new resolution on the economic advancement of women, focused mainly on women entrepreneurs. The narrow analysis of economic advancement was opposed by most delegations who favoured a more comprehensive and balanced approach to the issue of women and the economy. Through protracted negotiations many changes were made to the text, which eventually included references relevant to women as workers and caregivers, and to women's rights as workers (wage gap, social security, pensions, unpaid work and labour rights).
The negotiations were long and difficult and the final text remained highly unsatisfactory. It is possible that future applications of what is now 'agreed language' could be detrimental to the realization of women's economic rights. Carol Barton raises some controversial issues in her contribution to this issue of Development particularly around the tension and dichotomy around the negotiations on the economic resolution at the Beijing+10 meeting.
These negotiations were particularly difficult given the increased attention and understanding among feminists of the implications of trade and macroeconomic change for women's lives. The growing analysis indicates that the relationship between the macro-economy and gender equality runs two ways: macro-economic policies and trends can have different impacts by gender because of differences in the way that women and men are integrated into the economy. At the same time, gender biases in the functioning of markets may also have an impact on the effectiveness of macroeconomic policy by limiting the capacity of individuals and the economy to respond in the manner anticipated (CIDA, 2003). The analysis has included efforts to understand better how trade and other macro-economic policies affect women's health (The Corner House, 2004).
Examining how the sexual and reproductive health and rights of women are affected by and effect macro-economic policies is critical to the struggle. Trade agreements can affect all areas of women's lives and are particularly relevant in the drafting and implementation of labour laws and environmental policies. Monitoring how the General Agreement on Trade in Services (GATS) will affect the provision of health services internationally is also a crucial component in moving forward.
Barton provides an excellent analysis of the various trade and macro-economic policy decisions that can affect women's lives. She also discusses the tensions that have arisen between those working on macro-economic questions and those working on issues of sexual and reproductive health, arguing that there is a need for both to acknowledge the work of the other in order to develop a more strategic political agenda.
Certainly these issues are complex. Pragmatically, the international feminist lobby is unlikely to end the hegemonic neo-liberal economic agenda. Nevertheless, analysis and advocacy around international economic justice is key to continuing the broader struggle for economic justice. In the short term (another practical need), the analysis can make a difference in women's lives by pointing to the differential impact on women and the need for local and national mitigation strategies. Recognizing the continued need to focus on the imminent social justice issues facing women, including economic justice and sexual and reproductive health and rights, are critical to improving the day to day lives of women while at the same time striving for a more just world order.
It is possible to continue to make inroads even during these difficult political times. By examining the complexity of women's lives at the level of economic justice, by simultaneously pursuing strategies at the grassroots and the UN levels, by tackling internal contradictions within the movement and by pursuing further the rights-based approach, we can continue to nudge women towards greater empowerment and sexual and reproductive health and rights.
References
- CIDA (2003) 'Gender Equality and Trade-Related Capacity Building: A resource tool for practitioners', CIDA website.
- CIDA (2005) 'Bolivia: Stories from the Field: Sinovia's choice', CIDA website.
- Hawkins, Kirstan, Karen Newman, Deborah Thomas and Cindy Carlson (2005) 'Developing a Human Rights-Based Approach to Addressing Maternal Mortality: Desk review', DFID Health Resource Centre.
- Outlook (2003) 'A Rights-Based Approach to Reproductive Health', Programme for Appropriate Technology in Health (PATH).
- The Corner House (2004) 'Briefing 31, 'A Decade after Cairo: Women's health in a free market economy' by Sumati Nair and Preeti Kirbat with Sarah Sexton.
- UN (2005) 'In Larger Freedom: Towards development, security and human rights for all', Report of the Secretary General.
- UN Millennium Project (2005) Investing in Development: A practical plan to achieve the millennium development goals', UNDP, New York.
- WHO (2004) Maternal Mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA, Geneva: Department of Reproductive Health and Research.
Acknowledgements
Thanks are due to some of my colleagues at CIDA, particularly Louise Holt, Alison Van Rooy, Amrita Paul, Marie Powell and Elizabeth Sims.
