A REPRODUCTIVE HEALTH INDEX RIGHTS AND RESULTS

Transcription

1 A REPRODUCTIVE HEALTH INDEX RIGHTS AND RESULTS

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3 ACKNOWLEDGEMENTS PAI expresses its deep appreciatio to Michelle J. Hidi, Professor i the Departmet of Populatio, Family ad Reproductive Health at Johs Hopkis Bloomberg School of Public Health; Susheela Sigh, Vice Presidet for Research at Guttmacher Istitute; Gilda Sedgh, Seior Research Associate at Guttmacher Istitute; ad Michael Vlassoff, Seior Research Associate at Guttmacher Istitute for their ivaluable isights ad reviews of the coceptual framework ad methodology. Coceptual framework ad methodology by Kaja Jurczyska. Data collectio ad aalysis by Amadi Clarke ad Gia Sarfaty. Report arrative by Kim Ocheltree ad Gia Sarfaty. Graphics by Gia Sarfaty. Desig ad layout by Bospoit. Cotributios from: Elisha Du-Georgiou, Kately Bryat-Comstock, ad Daielle Zieliski. PAI, 2015 I 3 I A REPRODUCTIVE HEALTH INDEX

4 TABLE OF CONTENTS INTRODUCTION...3 EXECUTIVE SUMMARY...5 PREVENTING UNINTENDED PREGNANCY...13 INCREASING ACCESS TO SAFE ABORTION AND POST-ABORTION CARE...21 HELPING WOMEN SAFELY THROUGH PREGNANCY, CHILDBIRTH AND THE POSTPARTUM PERIOD...27 PREVENTING AND TREATING STIs, INCLUDING HIV/AIDS...35 ENABLING ENVIRONMENT FOR SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS...43 IN FOCUS: EQUITY...51 IN FOCUS: YOUTH...55 IN FOCUS: HUMANITARIAN SETTINGS...59 ANNEX I: COUNTRY INDICATORS AND INDEX SCORES...63 ANNEX II: CONCEPTUAL FRAMEWORK, DATA SOURCES AND METHODOLOGY...67 RIGHTS AND RESULTS I 1 I

5 I 2 I A REPRODUCTIVE HEALTH INDEX INTRODUCTION

6 The huma right to sexual ad reproductive health was eshried at the 1994 Iteratioal Coferece o Populatio ad Developmet more tha 20 years ago. Evidece cotiues to demostrate the beefits of ivestig i reproductive health. Yet, uiversal access to sexual ad reproductive health iformatio, services ad supplies is still ot a reality. Aroud the world, we still hear stories like these: A youg girl i Ghaa who caot eve visit a health ceter uaccompaied by a family member. A older woma i Cameroo with 12 childre, who wats to ed her childbearig i the hopes of makig some of her childre s dreams come true. A mother of two i Hoduras who risks her life as the result of a usafe abortio. A boy i Malawi who searches for iformatio to avoid a sexually trasmitted ifectio because his school does ot offer comprehesive sexuality educatio. The Reproductive Health Idex seeks to quatify the realizatio of sexual ad reproductive health ad rights (SRHR). More tha ay other health area, SRHR faces persistet barriers lack of high-level leadership ad political will, isufficiet fiacial ivestmet, weak health systems, geder iequity ad harmful social orms. This Idex eables us to uderstad the cocrete steps that coutries aroud the world are (or are ot) takig to fulfill citizes reproductive rights. Providig comprehesive, high-quality sexual ad reproductive health iformatio ad services is either a simple or easy udertakig but the beefits are well worth the effort. Eablig couples to space their childre leads to better health outcomes for wome ad childre. Girls with access to cotraceptio ca avoid uiteded pregacies, remai i school ad take advatage of a variety of opportuities. Ad healthier families who are able to ivest i their childre cotribute to household, commuity ad state-level developmet. Overall, cotraceptio cotiues to be oe of the most cost-effective developmet itervetios. Beyod all of these beefits to idividuals, families ad commuities lies the fudametal ratioale for ivestig i SRHR: people have a right to decide if ad whe to have childre. There are 1.79 billio wome of reproductive age aroud the world, ad by 2050 this umber is expected to grow to 2.15 billio wome. Every oe of them deserves to realize this right. Self-determiatio is a itegral part of the huma coditio. Idividuals thrive whe they are able to exercise cotrol over their lives, livelihoods ad their health. Reproductive selfdetermiatio is o differet. The world already kows how to esure that every idividual ca make his or her ow reproductive decisios. Now is the time to elevate SRHR as a top developmet priority at the global level ad a key atioal ivestmet at the coutry level. SRHR must have real commitmet, meaigful implemetatio ad wide-reachig accessibility if we ever hope to realize a world i which every girl ad boy ejoys a safe, healthy, prosperous life shaped by her ad his ow choices. RIGHTS AND RESULTS I 3 I

7 I 4 I A REPRODUCTIVE HEALTH INDEX EXECUTIVE SUMMARY

8 PURPOSE: Cotiuig a PAI effort begu i 1995, the Reproductive Health Idex is the fifth i a series of reports assessig the status of atios sexual ad reproductive health ad rights (SRHR). While our previous idices frame the issues i terms of sexual ad reproductive risk, this iteratio deliberately shifts its focus to how to achieve healthy sexual ad reproductive health ad realize rights. The aim is to provide a assessmet that icorporates a multi-dimesioal approach to reproductive health ad adds a ew perspective to how comprehesive SRHR is defied ad measured. The Idex ad its accompayig report provide a measure of where wome i 62 low- ad lower-middleicome coutries stad i attaiig sexual ad reproductive health ad rights. A coutry s Idex score aggregates key dimesios of SRHR ito a summary measure of achievemet. This summary measure offers a simple ad direct way to: uderstad a larger ad more complex set of issues, guide ivestmets, measure progress ad spur appropriate actio. Accordigly, the Idex serves as a catalyst for dialogue ad actio amog policymakers, program desigers, program implemeters, advocates ad doors alike. The Idex provides a sapshot of the status of wome s SRHR i each coutry ad allows stakeholders to see how coutries compare to oe aother. The Idex also provides isight o where gaps exist ad, cosequetly, where there are opportuities for targeted attetio ad ivestmet. Stregths ad weakesses amog regios ad coutries ca serve as drivig forces of chage. A coutry s Idex score ca also serve as a referece poit to assess how well govermet ivestmets, policies ad programs are respectig the rights ad meetig the eeds of wome. It is importat to ote that while idicators ad idices are valuable tools for broad aalysis, they caot measure the full scope of ay oe issue. A fuller picture of wome s SRHR status requires additioal aalysis. Accordigly, the chapters of our report provide a more i-depth look at the dimesios of SRHR ad provide aalysis of iformatio beyod the idicators used to costruct the Idex. RIGHTS AND RESULTS I 5 I

9 METHODOLOGY: Based o the 1994 Programme of Actio of the Iteratioal Coferece o Populatio ad Developmet, we defie SRHR accordig to the followig four dimesios: 1. Prevetig uiteded pregacy; 2. Icreasig access to safe abortio ad post-abortio care; 3. Helpig wome safely through pregacy, childbirth ad the postpartum period; ad 4. Prevetig ad treatig sexually trasmitted ifectios, icludig HIV/AIDS. A fifth dimesio, termed the eablig eviromet, captures factors beyod the health system that support sexual ad reproductive health ad rights. Rather tha measurig the health outcomes correspodig to the dimesios oted above, this Idex captures the factors drivig the attaimet of SRHR. Determiats iclude access to high-quality, volutary ad affordable health services ad supplies; highquality iformatio; ad o-restrictive ad o-coercive laws ad policies. To calculate a Idex score for each coutry, 11 idicators represetig the dimesios of SRHR were combied ito a sigle measure the Reproductive Health Idex. To view the list of idicators ad a full descriptio of how the Idex was costructed, please see the report Methodology o page 67. The Idex is scored o a 0 to 100 scale. Therefore, the strogest possible state of SRHR i a coutry accordig to the Idex would be a score of 100. FINDINGS: Idex scores for the 62 coutries icluded i our study rage from 25.5 to Though scores vary greatly withi that rage, the fact that o coutry received a score of 100 meas that there are opportuities to advace the sexual ad reproductive health ad rights of wome i all 62 coutries. HIGHEST CATEGORY (INDEX SCORES 80 TO 100) 1 COUNTRY Ukraie, a lower-middle-icome coutry, is the oly atio with a Idex score higher tha 80. Accordig to World Bak estimates, this Easter Europea coutry s gross atioal icome (GNI) per capita has rise by $460 from $3,500 i 2012 to $3,960 i This puts Ukraie s GNI per capita $165 away from beig a upper-middle-icome coutry. Idicators for Ukraie demostrate that: Niety-three percet of wome i Ukraie have their demad for cotraceptio satisfied ad 82 percet of wome were able to make a iformed choice about their cotraceptive method as a result of the iformatio they received from their health care providers. Ukraie does ot place policy restrictios o abortios. This meas uder Ukraie s legal framework, wome ca choose to have a abortio without restrictio as to reaso. A high percetage of wome i Ukraie are reported to receive at least four ateatal visits durig their pregacies ad almost 99 percet of births are atteded by skilled health persoel. More tha 90 percet of wome demostrate comprehesive kowledge of HIV prevetio methods. However, less tha half of the wome eligible for atiretroviral therapy are receivig treatmet. Idicators represetig a eablig eviromet were high for wome i Ukraie. Most wome (more tha 90 percet) were ot married as childre or adolescets ad almost 88 percet of married wome participate i all household decisios either aloe or joitly with their husbads. I 6 I A REPRODUCTIVE HEALTH INDEX

10 Ukraie Viet Nam Armeia Swazilad Republic of Moldova Cabo Verde Kyrgyzsta Cambodia Guyaa Zimbabwe Hoduras Liberia Mogolia Ghaa Rwada Keya Zambia Tajikista Bolivia (Pluriatioal State of) Sri Laka Sao Tome ad Pricipe Kiribati Vauatu Sierra Leoe Nepal Haiti Lesotho Cogo Solomo Islads Bei Bhuta Idia Togo Ugada Eritrea Burudi Philippies Malawi Uited Republic of Tazaia Idoesia Morocco Lao People's Democratic Republic Cameroo Nigeria Egypt Comoros Timor-Leste Burkia Faso Seegal Guiea-Bissau Mozambique Madagascar Democratic Republic of the Cogo Guiea Côte d'ivoire Ethiopia Mali Pakista Bagladesh Mauritaia Niger Chad INDEX RANKINGS AND CLASSIFICATION LOWEST LOW MIDDLE MID-HIGH HIGHEST RIGHTS AND RESULTS I 7 I

11 MID-HIGH CATEGORY (INDEX SCORES 60 TO 79) 16 COUNTRIES Coutries i this category are regioally diverse, with Asia, Europe, Lati America ad the Caribbea, ad Africa all represeted. The majority of coutries i this category are lower-middle-icome coutries. Data show that a average of 71 percet of wome i these coutries have their demad for cotraceptio satisfied. However, Ghaa ad Liberia are outliers, as less tha 40 percet of wome had their demad satisfied i these coutries. A average of early 58 percet of wome i this category were able to make a iformed choice about their cotraceptive method as a result of the iformatio they received from their health care providers. However, the ability of wome to make a iformed choice i Cabo Verde ad Mogolia is below 35 percet. Abortio is legal uder some circumstaces i all but oe coutry i this category; i Hoduras, abortio is prohibited. I eight of the 16 coutries, abortio is permitted without restrictio as to reaso. Additioally, 11 out of the 16 coutries have misoprostol (a drug that ca be used to effectively treat certai complicatios from usafe abortio) listed o their Essetial Medicie Lists. The majority of wome i these coutries report receivig at least four ateatal visits durig their pregacies, except i Rwada ad Keya, where ateatal coverage is below 50 percet. The majority of births (close to 80 percet) are atteded by skilled health persoel, with the exceptios of Keya ad Zambia, where skilled birth attedace is less tha 47 percet. The percetage of wome with a STI or potetial STI symptoms who sought advice or treatmet from a health professioal is less tha 64 percet o average. Geerally, wome i these coutries demostrate a high level of kowledge of HIV prevetio, ad a average of 71 percet of wome eligible for ati-retroviral therapy are receivig treatmet. However, atiretroviral coverage is otably low i Moldova, Mogolia ad Liberia. Eablig eviromet idicators reveal a average of 80 percet of wome were ot married as childre or adolescets ad 64 percet of married wome participate i all household decisios either aloe or joitly with their husbads. Household decisio-makig is particularly low i the sub-sahara Africa atios of Swazilad, Cabo Verde, Ghaa ad Zambia. MIDDLE CATEGORY (INDEX SCORES 40 TO 59) 36 COUNTRIES Twety of the 36 coutries i this category are from sub-sahara Africa. There is a ear equal split of low- ad lower-middle- icome coutries i this group. A average of 57 percet of wome i these coutries have their demad for cotraceptio satisfied ad a average of 57 percet of wome i this category were able to make a iformed choice about their cotraceptive method as a result of iformatio they received from their health care providers. Abortio is legal uder some circumstaces i 26 coutries i this category, two of which allow abortio without restrictio as to reaso. Abortio is prohibited altogether i te of the coutries i this category. Just over half of the 27 coutries i this group have I 8 I A REPRODUCTIVE HEALTH INDEX

12 misoprostol (a drug that ca be used to effectively treat certai complicatios from usafe abortio) listed o their Essetial Medicie Lists. LOW CATEGORY (INDEX SCORES 20 TO 39) 9 COUNTRIES Approximately 59 percet of wome i these coutries report receivig at least four ateatal visits durig their pregacies, ad 63 percet of births are atteded by skilled health persoel. The percetage of wome with a STI or potetial STI symptoms who sought advice or treatmet from a health professioal is 54 percet o average. Fifty-seve percet of wome i these coutries demostrate a high level of kowledge of HIV prevetio, ad less tha half of wome eligible for atiretroviral therapy are receivig treatmet. Atiretroviral coverage is as low as oe percet i Madagascar. Eablig eviromet idicators reveal that 70 percet of wome were ot married as childre or adolescets, ad oly 46 percet of married wome participate i all household decisios either aloe or joitly with their husbads. Household decisio-makig is particularly low i the sub-sahara Africa atios of Malawi, Cameroo, Burkia Faso ad Seegal. The majority of coutries i this category are low-icome coutries i sub-sahara Africa. With the exceptio of a few outliers, idicators for these coutries are low o both health ad the overall eablig eviromet. A average of oly 41 percet of wome i these coutries have their demad for cotraceptio satisfied, ad a average of less tha 37 percet of wome i this category were able to make a iformed choice about their cotraceptive method as a result of iformatio they received from their health care providers. Abortio is legal uder some circumstaces i eight coutries, but oe allow abortio without restrictio as to reaso. Abortio is prohibited altogether i oe coutry Mauritaia. Oly three coutries i this group have misoprostol listed o their Essetial Medicie Lists. Just over a third of wome i these coutries report receivig at least four ateatal visits durig their pregacies, ad less tha half of births (41 percet) are atteded by skilled health persoel. The percetage of wome with a STI or potetial STI symptoms who sought advice or treatmet from a health professioal is less tha 39 percet o average. Close to 41 percet of wome i these coutries demostrate a high level of kowledge of HIV prevetio, ad less tha half of wome eligible for atiretroviral therapy are receivig treatmet. Eablig eviromet idicators reveal less tha half of wome were ot married as childre or adolescets, ad oly 29 percet of married wome participate i all household decisios either aloe or joitly with their husbads. Household decisiomakig is particularly low i the sub- Sahara Africa atios of Mali ad Niger. LOWEST CATEGORY (INDEX SCORES 0 TO 19) 0 COUNTRIES Thakfully, o coutries had Idex scores that fell withi the lowest possible rage. RIGHTS AND RESULTS I 9 I

13 RECOMMENDATIONS: The Idex fidigs demostrate the eed for greater ivestmet i, ad targeted attetio to, fulfillig the SRHR of wome i all coutries icluded i the Idex. Accordigly, there is a eed to go beyod rhetorical commitmet to real actio for SRHR. SRHR must be cosidered a itegral compoet of ay health systems stregtheig approaches. Wome ad me, boys ad girls face a variety of SRHR eeds over the course of their lifetimes. Reproductive health should o loger be a siloed health cosideratio but rather should be addressed as a foudatioal aspect of overall health ad well-beig. Though gaps i meetig the eeds ad fulfillig the rights of wome may be larger i some coutries tha others, eve those coutries with higher scores have room to grow. Our aalysis idicates that improvig the SRHR of wome i these coutries depeds o three overarchig actios: Stregthe political will ad fiacial commitmets: At the atioal level, family plaig ad reproductive health programs with high-level political support ad sustaiable fiacial resources are more successful. This type of leadership ad commitmet are critical to esurig that policies promote meaigful access to cotraceptives, resources are made available ad reproductive health programs are prioritized. Craft ad implemet positive policies: There remais a eed to go beyod elimiatig policy barriers related to sexual ad reproductive health iformatio, services ad supplies. Policies eed to champio idividual reproductive rights, icludig amog historically disadvataged ad margialized populatios. For example, wome s reproductive autoomy should be esured beyod simply elimiatig spousal ad paretal coset regulatios. The reproductive health eeds of youth must be opely ackowledged i policies ad youth-friedly services eed to be prioritized ad itegrated withi existig programs. Provide quality iformatio ad services: Attetio is ofte cetered o attractig ew cotraceptive users to icrease cotraceptive prevalece rates. However, ivestig i high-quality iformatio, services ad supplies is critical for meetig the eeds of curret users. Prevetig uiteded pregacies depeds upo sustaiig satisfied cotraceptive users, ot simply acceptors. This requires greater emphasis o quality iformatio, couselig ad overall service delivery that meets the eeds of wome throughout their reproductive lives. I 10 I A REPRODUCTIVE HEALTH INDEX

14 SPECIFIC RECOMMENDATIONS THAT FALL WITHIN THE THREE CATEGORIES OF ACTION: Provide youth with age-appropriate comprehesive sexuality educatio i a safe eviromet. Provide access to quality reproductive health iformatio, services ad supplies. Make childbirth safer by providig adequate ateatal coverage, traiig ad deployig skilled birth attedats to perform deliveries, esurig facilities ca effectively maage complicatios ad provide emergecy care, ad esurig wome ca access quality, life-savig drugs. Implemet safe ad legal abortio services. Scale-up atiretroviral therapy ad itegrate STI ad HIV/AIDs programs with other health ad developmet iitiatives. Desig policies ad programs that reach all wome, icludig historically disadvataged ad margialized populatios. Ivest i buildig the capacity of health systems withi coutries to esure effective service delivery. Stregthe political will ad fiacial commitmets. Elimiate child, early ad forced marriage. Bolster a wome s decisio-makig power by icreasig access to formal educatio, providig wome with opportuities to ear their ow icome through the formal labor sector ad egagig commuities to trasform harmful social orms. For more iformatio about these recommedatios, please see our report chapters. RIGHTS AND RESULTS I 11 I

15 I 12 I A REPRODUCTIVE HEALTH INDEX PREVENTING UNINTENDED PREGNANCY

16 Oe of the corerstoes of healthy sexual ad reproductive health is the ability to decide if ad whe to have a child. Despite iteratioal affirmatios of a idividual s right to determie the umber, timig ad spacig of their childre, millios of people aroud the world are still ot able to realize this right. Of the 119 millio estimated pregacies i the developig world i 2008, 86 millio of these pregacies were uiteded. 1 These uiteded pregacies resulted i 33 millio uplaed births ad 41 millio abortios. 2 These millios of uiteded pregacies also represet a failure to realize the reproductive rights of millios of wome aroud the world. Curretly, cotraceptive services reach a estimated 603 millio wome ad prevet 188 millio uiteded pregacies. 3 As a result, more tha 200,000 materal deaths ad more tha oe millio ewbor deaths are averted. 4 But ot all wome s reproductive health eeds are beig met. Globally, 225 millio wome have a umet eed for family plaig. 5 These are wome who wat to delay or limit childbearig but are ot curretly usig cotraceptio. Withi all these statistics rests the potetial for poor health outcomes, pregacy complicatios, materal morbidity ad mortality ad ewbor mortality. Recet estimates show that satisfyig umet eed for cotraceptio could reduce materal mortality by 29 percet. 6 Healthily spaced pregacies lead to better health outcomes for mothers, their ew babies ad their other childre. 7 Plaed pregacies also have bee associated with healthier behaviors, icludig seekig ateatal care, breastfeedig ad vacciatio. 8 Plaed ad well-spaced pregacies ca oly be achieved through access to highquality cotraceptive iformatio, services ad supplies. Access to cotraceptio also eables girls to prevet uplaed pregacies improvig their ability to stay i school. Better-educated girls grow ito wome poised to pursue ecoomic ad employmet opportuities. 9 RIGHTS AND RESULTS I 13 I

17 O the other had, lack of access to cotraceptive iformatio, services ad supplies puts lives at risk. Adolescets are particularly vulerable to obstetric complicatios ad, therefore, face greater health risks from early, uiteded pregacies. Girls aged 15 to 19 are twice as likely to die from obstetric causes as older wome. 10 Older wome also face risks from uiteded pregacies, particularly whe they are ot healthily spaced. Wome with short itervals betwee births (less tha five moths betwee birth ad their ext pregacy) face a risk of materal death 2.5 times greater tha wome with loger birth itervals (18 23 moths betwee birth ad their ext pregacy) A CLOSER LOOK INDICATORS FROM THE INDEX Though there are a variety of complex ad coected elemets that cotribute to prevetig uiteded pregacies, for our Idex we selected two idicators to measure this dimesio of sexual ad reproductive health ad rights (SRHR): the percet demad satisfied for cotraceptio amog curretly married wome; ad a composite measure of iformed choice. The first idicator percet demad satisfied for cotraceptio amog curretly married wome represets a importat idicator aroud access. While this idicator does ot measure the quality of family plaig iformatio, services or supplies, it does provide a picture of wome s ability to access cotraceptive methods. The secod idicator iformed choice is a composite of three measures: percet of moder users iformed of side effects, percet who were iformed about what to do if side effects occur, ad percet who were iformed of other methods available. This secod idicator captures provisio of iformatio as a importat quality compoet of reproductive health service delivery. The two idicators were selected to complemet each other by pairig a access measure with a quality-based idicator. I selectig these idicators, we also cosidered the availability of comparable, high-quality atioal data. For more iformatio o the selectio of all the Idex idicators, refer to the Methodology o page 67. TRENDS AND HIGHLIGHTS More tha 200 millio wome worldwide cotiue to have a umet eed for family plaig. 12 The lack of cotraceptive use captured by umet eed may result from a rage of factors, icludig: a iability to access cotraceptive services, fiacial barriers, cocers over side effects, lack of kowledge ad cultural or religious objectios. 13 Amog the coutries fallig i the lowest category * o our Idex (Guiea, Côte D Ivoire, Ethiopia, Mali, Pakista, Mauritaia, Niger ad Chad), the percetage of married wome aged with a umet eed for family *Excludes Bagladesh

18 Umet UNMET NEED Need FOR FAMILY for Family PLANNINGPlaig Percetage of curretly married wome with a umet eed for family plaig Viet Nam Ukraie Guiea-Bissau Sri Laka Republic of Moldova Hoduras Morocco Solomo Islads Idoesia Egypt Bhuta Swazilad Armeia Bagladesh Zimbabwe Mogolia Niger Nigeria Cambodia Cabo Verde Philippies Kyrgyzsta Cogo Madagascar Lao People's Democratic Republic Bolivia (Pluriatioal State of) Pakista Rwada Idia Uited Republic of Tazaia Tajikista Lesotho Cameroo Guiea Vauatu Burkia Faso Sierra Leoe Keya Mali Malawi Ethiopia Zambia Côte d'ivoire Eritrea Nepal Democratic Republic of the Cogo Kiribati Chad Guyaa Mozambique Seegal Liberia Mauritaia Timor-Leste Comoros Burudi Bei Ugada Haiti Ghaa Togo Sao Tome ad Pricipe Sources: DHS, MICS, ad atioal surveys. plaig rages from 16 to 31.1 percet. 14 Comparatively, i Swazilad (Idex Score: 75.0/100), a top-rakig coutry, 13 percet of wome have a umet eed for family plaig. 15 Almost 90 percet of the toprakig coutries o our Idex have a demad satisfied of 60 percet of wome or higher. Satisfyig demad for cotraceptive iformatio, services ad supplies is tied to a strog, ofte mature family plaig program. Coutries seeig relatively rapid gais i cotraceptive use like Malawi, Rwada ad Seegal ca poit to highlevel political ad fiacial commitmets as critical to programmatic strides. (for more o Rwada, see Risig Star box o page 18). Coutries rakig i the middle ad low categories of the Idex have more mixed results o the demad satisfied idicator. For example, Bagladesh raks almost at the bottom of the overall Idex, but its percetage demad satisfied for married wome is 81.6 percet. Most West Africa coutries fall i the middle or low categories of the Idex, ad oe of these coutries, except Guiea-Bissau, break 50 percet of cotraceptive demad satisfied. Prior to the Ouagadougou Declaratio of 2011, may West Africa coutries lacked political commitmet to family plaig, which kept it a low priority. Mobilizig govermet support, icludig fiacial resources, will be essetial to further progress i the West Africa regio. *Sierra Leoe, Bei, Togo, Nigeria, Burkia Faso, Seegal, Guiea-Bissau, Guiea, Côte d Ivoire, Mali, Mauritaia ad Niger. RIGHTS AND RESULTS I 15 I

19 Treds aalysis aroud quality ad choice is limited because of availability of data i these areas. Eve our selected iformed choice idicator fails to aswer several importat questios: Are wome receivig their method of choice? Is full method mix available? The iformed choice idicator oly captures the provisio of iformatio as a quality cosideratio aroud family plaig service delivery. The iformed choice idicator has a sigificat diversity of results that are ot tied to a coutry s overall performace o the Idex. For example, Cabo Verde (Idex Score: 73.0/100) ad Hoduras (Idex Score: 68.0/100) score relatively highly o the overall Idex but have low scores o the iformed choice idicator (Cabo Verde: 31.1; Hoduras: 47.5). Such results draw a importat distictio: Access does ot equal quality. While a substatial portio of wome i coutries may have their demad for cotraceptio satisfied, this does ot ecessarily mea accurate ad comprehesible cotraceptive iformatio is provided at service delivery poits. Evidece has show that may cotraceptive users discotiue due to side effects. For example, oe study i Nepal (Idex Score: 55.6/100) showed that side effects were the most frequetly cited reaso for discotiuig oral cotraceptive pills, IUCDs, ijectables ad implats. 16 Providig uderstadable, evidece-based iformatio i cojuctio with repeated couselig ecouters with welltraied providers ca decrease discotiuatio. Attetio caot solely be cetered o attractig ew cotraceptive users to icrease cotraceptive prevalece rates. Ivestig i high-quality iformatio, services ad supplies is critical for meetig the eeds of curret users ad reducig discotiuatio. Other quality cosideratios that are essetial to respectig ad protectig reproductive rights iclude: esurig wome have a choice amog a rage of cotraceptive methods; providers are well-traied, equipped ad supported to provide high-quality services; ad policies ad guidelies support equitable ad odiscrimiatory provisio of cotraceptive iformatio, services ad supplies. For example, coutries are icreasigly embracig task shiftig distributio I 16 I A REPRODUCTIVE HEALTH INDEX

20 of cotraceptives by lower-level health workers as a mechaism for icreasig access to a rage of cotraceptive methods. This approach further promotes cotraceptive choice. The Health Extesio Worker program i Ethiopia (Idex Score: 39.1/100) has cotributed to a doublig of cotraceptive use from 13.9 percet of curretly married wome aged i 2005 to 27.3 percet i Despite beig a relatively low-rakig coutry, improvig access to cotraceptives is a area where Ethiopia has made strides. Despite the risks of uiteded pregacies, access to affordable, quality cotraceptio remais ueve. Adolescets are particularly vulerable to obstetric complicatios ad, therefore, face greater health risks from early uiteded pregacies. Eve with these dagers, adolescets must ofte overcome fiacial, cultural ad access barriers to obtai safe, high-quality cotraceptive services. For example, i Timor-Leste (Idex Score: 46.7/100), less tha oe percet of married wome aged were usig a moder method of cotraceptio, compared to seve percet ad 23.8 percet amog wome aged ad 30 34, respectively. 18 For more iformatio o youth, see the Youth sectio o page 55. ACTIONS FOR PREVENTING UNINTENDED PREGNANCY Stregthe political will ad fiacial commitmets: At the atioal level, family plaig programs with high-level political support ad sustaiable fiacial resources are more successful. This type of leadership ad commitmet are critical to esurig that policies promote meaigful access to cotraceptives, resources are made available ad reproductive health programs are prioritized. Craft positive policies: There remais a eed to go beyod elimiatig policy barriers related to cotraceptive iformatio, services ad supplies. Policies eed to champio idividual reproductive rights, icludig amog historically disadvataged ad margialized populatios. For example, wome s reproductive autoomy should be esured beyod simply elimiatig spousal ad paretal coset regulatios. The reproductive RIGHTS AND RESULTS I 17 I

21 health eeds of youth must be opely ackowledged i policies, ad youthfriedly services eed to be prioritized ad itegrated withi existig programs. Provide quality iformatio ad services: Attetio is ofte cetered o attractig ew cotraceptive users to icrease cotraceptive prevalece rates. Prevetig uiteded pregacies depeds upo sustaiig satisfied cotraceptive users, ot simply acceptors. This requires greater emphasis o quality iformatio, couselig ad overall service delivery that meets the eeds of wome throughout their reproductive lives. Expad method mix: Esurig the availability of a rage of cotraceptive methods represets a critical part of offerig high-quality cotraceptive services. Idividuals must be able to access the cotraceptive method of their choice. May coutries have bee embracig task-shiftig, a approach that expads access to cotraceptives at the commuity level, particularly for pills ad ijectables. I additio to the availability of skilled providers, effective supply chais are critical to esurig that a rage of methods are available at poits of service. RISING STAR RWANDA I 2005, the presidet ad prime miister of Rwada agreed that family plaig was a issue that could o loger be igored. Betwee 2005 ad 2010, Rwada s umet eed for family plaig declied from 39 percet to 24 percet amog married wome of reproductive age. 19 Durig the same time period, the met eed for family plaig dramatically icreased from oly 17 percet to 52 percet. 20 High-level political support for the family plaig program icluded the presidet, parliametarias ad the Natioal Assembly, as well as local govermet officials at the district ad commuity levels. Family plaig services ad commodities are free of charge i Rwada. 21 I additio to effective leadership ad commitmet, Rwada embraced task-shiftig ad made sigificat improvemets to its supply chai ad logistics maagemet systems for cotraceptives. 22 The govermet ad its developmet parters also committed to the eed for skilled providers at health facilities to expad method mix. These strategies, alog with other itervetios, have eabled Rwada to make tremedous strides i meetig the cotraceptive eeds of its citizes. As a result, cotraceptive prevalece icreased four-fold, ad the coutry also experieced impressive declies ifat ad materal mortality. I 18 I A REPRODUCTIVE HEALTH INDEX

22 Edotes 1 Sigh, Susheela, Sedgh, Gilda, ad Hussai, Rubia. Uiteded pregacy: Worldwide levels, treds ad outcomes. Studies i Family Plaig, Volume 41, Issue 4, Ibid. 3 Guttmacher Istitute ad UNPFA. Addig It Up: The Costs ad Beefits of Ivestig i Family Plaig ad Materal ad Newbor Health. New York, Guttmacher Istitute, Ibid. 5 Ibid. 6 Ahmed, Saifuddi, Li, Qigfeg, Liu, Li ad Tsui, Amy. Materal deaths averted by cotraceptive use: a aalysis of 172 coutries. The Lacet, Volume 380, Issue 9837, Norto, M. New evidece o birth spacig: promisig fidigs for improvig ewbor, ifat, child ad materal health. Iteratioal Joural of Gyecology ad Obstetrics, Volume 89, Supplemet 1, Gipso, Jessica, Koeig, Michael ad Hidi, Michelle. The effects of uiteded pregacy o ifat, childre ad paretal health: A review of the literature. Studies i Family Plaig, Vol 39, Issue 1, Ceter for Reproductive Rights. Access to Cotraceptives: The Social ad Ecoomic Beefits ad Role i Achievig Geder Equality. Washigto, DC: Ceter for Reproductive Rigts, Populatio Referece Bureau. Family Plaig Saves Lives. Washigto, DC: PRB, Ibid. 12 Guttmacher Istitute ad UNFPA. Addig It Up: The Costs ad Beefits of Ivestig i Sexual ad Reproductive Health. New York, Guttmacher Istitute, Gribble, James. Fact Sheet: Umet eed for family plaig. World Populatio Data Sheet Uited Natios Populatio Divisio Update for the MDG Database: Umet Need for Family Plaig. 15 Ibid. 16 U.S. Agecy for Iteratioal Developmet (USAID) ad EgederHealth. Cotraceptive use ad discotiuatio patters i Nepal: Norplat, IUCD, Pill ad Ijectables. New York: Egeder Health, USAID, Ethiopia Federal Miistry of Health, Malawi Miistry of Health, ad Rwada Miistry of Health. Three Successful Sub-Sahara Africa Family Plaig Programs: Lessos for Meetig the MDGs. Washigto, DC: USAID, ICF Iteratioal Demographic ad Health Survey: Timor-Leste. Fairfax, VA: ICF: USAID, Ethiopia Federal Miistry of Health, Malawi Miistry of Health, ad Rwada Miistry of Health. Three Successful Sub-Sahara Africa Family Plaig Programs: Lessos for Meetig the MDGs. Washigto, DC: USAID, Ibid. 21 Ibid. 22 Ibid. RIGHTS AND RESULTS I 19 I

23 I 20 I A REPRODUCTIVE HEALTH INDEX INCREASING ACCESS TO SAFE ABORTION AND POST-ABORTION CARE

24 Whe wome are faced with a uiteded or usafe pregacy, they should be able to access comprehesive, safe abortio services. Wome ad couples aroud the world should have the iformatio ad meas to decide freely ad for themselves whether, whe ad how may childre to have. Every pregacy should be plaed ad desired. Ufortuately, ot every woma is able to access cotraceptive iformatio, services ad supplies ad may experiece cotraceptive failures or sexual violece all of which ca lead to uiteded pregacies. Of the estimated 80 millio uiteded pregacies each year, over 50 percet of them result i a iduced abortio. 1 For millios of wome i the developig world, there is o access to safe abortio services. Restrictive laws ad policies force wome aroud the world to resort to usafe abortios decisios that ca result i a host of serious complicatios ad eve death. The World Health Orgaizatio defies a usafe abortio as a procedure for termiatig a uiteded pregacy carried out either by persos lackig the ecessary skills or i a eviromet that does ot coform to miimal medical stadards, or both. 2 Usafe abortios are etirely prevetable whe wome ca use cotraceptio to pla pregacies, have access to safe abortio services ad also have the autoomy to make decisios about their reproductive lives. The vast majority of uiteded pregacies occur because wome caot access quality cotraceptive iformatio, services ad supplies. Accessibility ad availability of cotraceptive services reduces reliace o abortio. From 1990 to 2011, icreased ivestmet ad support for family plaig programs cotributed to decreased abortio rates across Easter Europe. 3 However, lack of accurate iformatio represets a major barrier to accessig cotraceptio. Lack of iformatio or o access to comprehesive sexuality educatio puts wome ad girls at greater risk of uiteded pregacies ad usafe abortio (for more iformatio o adolescets, see the Youth sectio o page 55). More tha half of the estimated 80 millio uiteded pregacies each year result i abortio. 4 More tha 21 millio wome worldwide had usafe abortios i 2008, but wome i the developig coutries are disproportioately forced to resort to usafe abortio compared to wome i the developed world. 5 Almost all usafe abortios approximately 98 percet occur i the developig world. 6 Wome i the developig world cotiue to risk death ad life-threateig complicatios i obtaiig a abortio. Estimates from 2008 show that abortio-related deaths accouted for 13 percet of all materal deaths worldwide. 7 RIGHTS AND RESULTS I 21 I

25 I additio to the tes of thousads of wome who die from usafe abortio, a estimated five millio more wome will edure other post-abortio complicatios. 8 Betwee percet of wome who udergo usafe abortios ed up i a health facility for complicatios. 9 These complicatios iclude aemia, prologed weakess, reproductive tract iflammatio ad secodary ifertility. 10 Comprehesive post-abortio care programs represet a critical piece of the health systems + A CLOSER LOOK INDICATORS FROM THE INDEX i cotexts where abortio cotiues to be legally restricted ad usafe abortios are the oly recourse for wome. Post-abortio care refers to a package of services that iclude: treatig complicatios from usafe abortios, providig family plaig couselig ad service delivery to prevet future abortios ad provisio or referral for ay other ecessary health service. For post-abortio care programs to effectively prevet, maage ad treat potetial complicatios, traied staff must have the ecessary supplies ad May factors cotribute to icreasig access to safe abortio ad post-abortio care. For our Idex, we selected two idicators to measure this dimesio of sexual ad reproductive health ad rights (SRHR): the grouds o which abortio is permitted; ad the status of misoprostol for post-abortio care o the atioal Essetial Medicies List (EML). The first (the grouds upo which abortio is permitted) was selected because rates of usafe abortio are associated with strict legal restrictios. The secod idicator (the status of misoprostol for post-abortio care o atioal EMLs) represets a measurable policy compoet of well-fuctioig post-abortio care programs. Misoprostol ca be used to effectively treat certai complicatios from usafe abortio; however, it must be effectively itegrated ito post-abortio care programs. The first step i such itegratio is icludig misoprostol o a atioal EML specifically uder a post-abortio care idicatio. I selectig these two idicators, we also cosidered the availability of comparable, highquality atioal data. For more iformatio o the selectio of all the Idex idicators, refer to the Methodology o page 67. be workig uder the most recet service delivery guidelies. Esurig healthy sexual ad reproductive health meas eablig idividuals to realize their reproductive rights, icludig access to safe abortio ad post-abortio services. TRENDS AND HIGHLIGHTS Globally, approximately oe i te pregacies eds i a usafe abortio. 11 Sice 2003, the global rate of usafe abortio 14 per 1,000 wome aged has remaied uchaged. 12 Rates of usafe abortio are highest i Africa ad Lati America. 13 However, there are sigificat regioal differeces across Africa. Easter ad Middle Africa s usafe abortio rate is 36 per 1,000 wome aged 15 44, the highest rate for ay sub-regio i the world. 14 I Tazaia (Idex Score: 50.6/100) for istace, oe study showed that amog wome presetig with abortio complicatios at a hospital, 46 percet ad 60 percet of the procedures were performed by a uskilled provider i rural ad urba areas, respectively. 15 I 22 I A REPRODUCTIVE HEALTH INDEX

26 I settigs where access to safe abortio is legally restricted, the percetage of usafe procedures icreases. Eight of the top ie coutries i our Idex Ukraie, Vietam, Armeia, Moldova, Cabo Verde, Kyrgyzsta, Cambodia, Guyaa all allow abortio without restrictio as to reaso. Amog coutries raked i the high category o the Idex, 75 percet of coutries allow abortio without restrictio as to reaso, for socioecoomic reasos or to preserve the woma s metal health. Comparatively, oly two coutries raked i the middle of the Idex allow abortio without restrictio ad 10 coutries prohibit abortio all together. Lookig at policy restrictios aloe, however, does ot provide the full picture, particularly with regard to implemetatio. For example, i Cambodia (Idex Score: 69.5/100), a 2005 survey of health facilities foud that 40 percet of health staff i hospitals still believed that abortio was illegal; these miscoceptios persisted despite the fact the law was chaged i The ie coutries that fall at the bottom of the Idex rakigs have much stricter policies that limit the circumstaces uder which abortio ca be performed. Ethiopia, Guiea, Pakista, Niger ad Chad allow abortio to preserve a woma s physical health; Mali oly allows abortio to save a woma s life or i the case of rape or icest; ad Côte D Ivoire ad Bagladesh* allow abortio to save a woma s life. Mauritaia etirely prohibits abortio. Eve whe coutries formal legal While abortio is legally prohibited, mestrual regulatio is a authorized procedure i Bagladesh. policies allow abortio procedures uder certai circumstaces, there are frequetly difficult documetatio requiremets that effectively prohibit wome s ability to obtai a safe ad legal abortio. Not surprisigly, usafe abortios ofte result i serious ad potetially lifethreateig complicatios. For example, i Burkia Faso (Idex Score: 45.6/100) there were a estimated 105,000 abortios i 2012, the majority of which were usafe. 17 YOUTH SPOTLIGHT Estimates show that approximately 43 percet of wome i Burkia Faso udergoig a usafe abortio had serious complicatios requirig treatmet. 18 Quality post-abortio care programs ca mitigate the likelihood that wome will die or have lifelog disabilities resultig from a usafe abortio. Misoprostol has become a icreasigly itegral part of materal health ad post-abortio care i recet years. While more tha 64 percet of coutries o the I settigs where abortio is illegal, adolescet girls are more likely to have a usafe abortio ad risk potetial complicatios. I Africa, over 51 percet of usafe abortios were amog wome uder age Sigificat umbers of wome aroud the world report that their sexual debut was coerced. 20 Youg wome are at greater risk of uiteded pregacies but also recogize the sigs of pregacy later ad struggle to access ad pay for quality services. These factors work together to put adolescets at greater risk of sufferig complicatios from usafe abortio. Estimates show that girls aged accout for 70 percet of all hospitalizatios from usafe abortio. 21 Adolescets eed the tools to exercise safe ad healthy decisios aroud their reproductio health. Effective, comprehesive sexuality educatio ca icrease the use of cotraceptio, reduce misiformatio, reiforce positive attitudes ad improve skills for decisiomakig. 22 Age-appropriate sexuality educatio provided i a safe eviromet is critical to esurig the largest youth cohort i history is prepared to make decisios about their reproductive health, avoid uiteded pregacies ad avoid sufferig life-log complicatios from a usafe abortio. RIGHTS AND RESULTS I 23 I

27 Idex have misoprostol o their EMLs, oly seve coutries have actually icluded postabortio care idicatios for misoprostol: Eritrea, Ghaa, Hoduras, Keya, Liberia, Nigeria ad Zimbabwe. While this does ot mea that the use of misoprostol is ecessarily prohibited, icludig a post-abortio care idicatio o the EML makes it more likely that misoprostol for treatig icomplete abortio is icluded i other importat guidelies, like service delivery guidelies. ACTIONS FOR INCREASING ACCESS TO SAFE ABORTION AND POST-ABORTION CARE Access to safe abortio ad post-abortio care ca be esured through several key approaches: Esure access to cotraceptive iformatio, services ad supplies: Cotraceptive accessibility ad availability decreases the reliace o usafe abortio ad should be a stadard part of ay post-abortio care package. Three out of four usafe abortios could be elimiated if wome s eeds for family plaig were satisfied. 23 Remove legal restrictios o abortio: Wome are likely to have a iduced abortio whe faced with a uiteded pregacy, regardless of the legal status of abortio. Legal restrictios o abortio must be elimiated because they do ot prevet abortios; rather, these restrictio force wome to resort to usafe abortios. Restrictive laws affect ot oly access to safe services but also access to accurate ad adequate iformatio. Wome i these settigs are ofte ot provided with complete, accurate ad uderstadable iformatio about their pregacies ad safe abortio services (if allowed uder certai circumstaces). 24 Implemet safe ad legal abortio services: Relaxig or elimiatig legal restrictios o abortio is oly a effective strategy if policy chages are effectively implemeted. Liberalizig laws is a first step, but implemetatio must be supported to esure improved access to safe abortio services. The implemetatio of less-restrictive laws eeds to be commuicated through clear, accessible guidelies to facilities, service providers ad beeficiaries. Oce abortio laws become less restrictive, there are a rage of actios that must be take to esure they are implemeted ad lead to improved access to services. Providers must be properly traied, equipmet ad medicies RISING STAR NEPAL I 2002, the Nepali Parliamet legalized abortio to allow: abortio for ay reaso up to 12 weeks of gestatio; i the case of rape or icest up to 18 weeks of gestatio; up to ay stage of gestatio if the woma s life is at risk. 25 Sice 2004, safe abortio services have bee made available, icludig medical abortio i limited settigs. Betwee 2005 ad 2013, the materal mortality ratio i Nepal declied from 310 to 190 materal deaths per 100,000 live births oe of the lowest materal mortality ratios amog developig coutries i Asia. 26 Nepal did ot simply legalize abortio but took the ecessary steps to esure that wome had meaigful access to safe abortio services. I coordiatio with parters, the govermet implemeted a program to trai providers, icludig staff urses ad auxiliary urse midwives, to perform abortios. 27 The program also improved kowledge about legal abortio ad its availability i Nepal. 28 Oe study showed a declie i the severity of abortio-related complicatios followig the legalizatio of abortio. 29 The steepest declie i abortio complicatios occurred durig the period , durig which time the abortio program expaded. 30 Legalizig abortio services remais a first step toward esurig that wome have access to safe reproductive health iformatio ad services. Nepal is a clear example of a coutry that effectively traslated a sigificat abortio policy chage ito available services. I 24 I A REPRODUCTIVE HEALTH INDEX

28 must be itegrated ito the health system ad efforts must be udertake to address the stigma surroudig abortio. Expad post-abortio care services: Quality post-abortio care is critical for prevetig devastatig, ofte life-log disabilities ad deaths due to usafe abortios. Postabortio care services require the availability of quality supplies, both misoprostol ad maual vacuum aspiratio kits, ad traied staff to employ these supplies. I order to effectively itegrate misoprostol ito postabortio care programs, it eeds to be icluded o atioal EMLs ad to be actually procured ad make it to facilities where services are delivered. Edotes 1 World Health Orgaizatio (WHO). Safe ad Usafe Iduced Abortio: Global ad regioal levels i 2008 ad treds durig , WHO_RHR_12.02_eg.pdf 2 Ibid. 3 U.S. Agecy for Iteratioal Developmet. Family Plaig i Easter Europe ad Eurasia: a legacy of chage. Washigto, DC: USAID, WHO. Safe ad Usafe Iduced Abortio: Global ad regioal levels i 2008 ad treds durig , Ibid. 6 Ibid. 7 WHO. Global ad Regioal Estimates of the Icidece of Usafe Abortio ad Associated Mortality i th ed., Geeva: WHO, WHO. Safe Abortio: techical ad policy guidace for health systems, 2d editio. Geeva: WHO, Grimes, David A, et al. Usafe abortio: the prevetable pademic. The Lacet Sexual ad Reproductive Health Series, October WHO. Usafe Abortio Icidece ad Mortality: Global ad regioal levels i 2008 ad treds durig WHO. Safe ad Usafe Iduced Abortio: Global ad regioal levels i 2008 ad treds durig , Ibid. 14 Ibid. 15 Guttmacher Istitute. I Brief: Fact Sheet Usafe Abortio i Tazaia, Guttmacher Istitute. News Release: Legalizatio aloes does ot guaratee availability of safe abortio services, Malter, Jessica. Usafe Abortio is Widespread i Burkia Faso. New York: Guttmacher Istitute, Ibid. 19 Shah, IH, Ahma, E. Usafe abortio differetials i 2008 by age ad developig coutry regio: high burde amog youg wome. Reproductive Health Matters, 20(39): , UN Populatio Fud (UNFPA). Comprehesive Sexuality Educatio: Advacig huma rights, geder equality ad improved sexual ad reproductive health. New York, UNFPA, Pla Iteratioal. Because I am a girl: The state of the world s girls Surrey, UK: Pla Iteratioal, UNFPA. Comprehesive Sexuality Educatio: Advacig huma rights, geder equality, ad improved sexual ad reproductive health. New York, UNFPA, WHO. Safe ad Usafe Iduced Abortio: Global ad regioal levels i 2008 ad treds durig , Ceter for Reproductive Rights ad UNFPA. ICPD ad Huma Rights: 20 years of advacig reproductive rights through UN treaty bodies ad legal reform. Washigto, DC: Ceter for Reproductive Rights, Puri M, Regmi S, Tamag A, Shrestha P. Road map to scalig-up: traslatig operatios research study s results ito actios for expadig medical abortio services i rural health facilities i Nepal. Health Research Policy ad Systems, 12:24, doi: / WHO, UNICEF, UNFPA, The World Bak ad the UN Populatio Divisio. Treds i Materal Mortality: 1990 to Geeva: WHO, JT Hederso et al. Effects of abortio legalizatio i Nepal, PLoS Oe, May 31;8(5):e64775, doi: /joural.poe G Samadari et al. Implemetatio of legal abortio i Nepal: a model for rapid scale-up of high-quality care. Reproductive Health, 9:7, doi: / JT Hederso et al. Effects of abortio legalizatio i Nepal, PLoS Oe, May 31;8(5):e64775, doi: /joural.poe Ibid. RIGHTS AND RESULTS I 25 I

29 HELPING WOMEN SAFELY THROUGH PREGNANCY, CHILDBIRTH AND THE POSTPARTUM PERIOD I 26 I A REPRODUCTIVE HEALTH INDEX

30 The ability to have a healthy pregacy ad safe delivery is aother essetial compoet of realizig overall sexual ad reproductive health ad rights (SRHR). Throughout pregacy, childbirth ad the postpartum period, quality reproductive ad materal health care ca effectively esure positive health outcomes for wome ad their childre. Materal mortality has falle sigificatly over the past two decades. The global materal mortality ratio (MMR) has dropped from 380 to 210 materal deaths per 100,000 live births from 1990 to As of 2013, 19 coutries had achieved Milleium Developmet Goals target 5.A (reduce by three-quarters the materal mortality ratio): Belarus, Bhuta, Bulgaria, Cabo Verde, Cambodia, Equatorial Guiea, Eritrea, Estoia, Ira, Israel, Lao People s Democratic Republic, Latvia, Lebao, Lithuaia, Maldives, Nepal, Oma, Polad, Romaia, Rwada, Timor- Leste ad Vietam. 2 Access to cotraceptio allows idividuals to pla pregacies, which cotributes to decreased risk of materal death (ad decreased risk of ewbor death, preterm birth ad low weight birth). 3 Other positive global treds icludig lower fertility rates, higher rates of female educatio ad icreased gross domestic product (GDP) per capita have also cotributed to the declie i materal mortality. Despite this otable progress, a estimated 289,000 wome die aually from pregacy-related causes early all i the developig world. 4 Prevetig materal deaths ad disability relies o the availability ad accessibility of quality ateatal care ad safe delivery. I low-icome coutries, prevetable causes such as hypertesio ad hemorrhage are still the drivig force behid materal deaths. The risk of dyig from preeclampsia ad eclampsia is approximately 300 times higher for a woma i a developig coutry tha for a woma i a higher icome coutry. For every woma who dies of pregacy-related causes, a estimated wome experiece severe or lifelog morbidity. 5 RIGHTS AND RESULTS I 27 I

31 From obstructed fistula to severe aemia, sustaied ijuries related to pregacy ad childbirth affect more tha 20 millio wome aually. 6 These ijuries ca have life-log effects o wome s physical, metal ad sexual health ad impact their social ad ecoomic status. Delays i recogizig complicatios ad seekig care, reachig the appropriate facility ad receivig care oce at a facility are sigificat challeges to providig adequate ad timely care i the evet of a obstetric emergecy. 7 Materal deaths disproportioately affect those with the poorest access to health services. High materal mortality ad morbidity most ofte result from iadequate care through the precoceptio, ateatal, delivery ad postpartum stages. As such, they ofte reflect a weak overall health system. May of the challeges experieced withi the broader health system icludig staffig, supplies, iadequate fiacig ad poor ifrastructure directly impact the quality of care ecessary for wome to safely avigate through pregacy, childbirth ad the postpartum period. Quality materal health care icludes respect for patiets. Emergig evidece has show that abusive treatmet of wome durig childbirth is a pervasive tred experieced at differet levels i may coutries. Ragig from verbal abuse to physical puishmet ad coercio, disrespectful ad abusive care deters utilizatio of health services ad compromises the rights of wome ad girls seekig care. 8 + A CLOSER LOOK INDICATORS FROM THE INDEX Itervetios exist to ed prevetable materal deaths, but helpig wome safely through pregacy, childbirth ad the postpartum period requires sustaied ivestmet ad commitmet. Govermets Helpig wome safely through pregacy, childbirth ad the postpartum period requires a series of health approaches ad itervetios. For our Idex, we selected two idicators to measure this dimesio of SRHR: the percetage of wome receivig at least four ateatal care visits; ad the percetage of births atteded by skilled health persoel. While there are a variety of idicators available that relate to the state of materal health, these two idicators represet corerstoes of quality materal health care. Comprehesive ateatal care is critical to idetifyig potetial complicatios early so that a woma s pregacy ca be moitored, treatable coditios ca be addressed ad families ca pla to have a skilled attedat for complicated births. I additio, wome ca also receive microutriet supplemetatio, tetaus immuizatios, HIV testig ad treatmet, malaria medicatio ad isecticide-treated bed ets through ateatal care services. 9 Safe delivery requires well-traied ad supported health persoel, icludig midwives; facilities equipped with supplies ad medicies to respod to obstetric complicatios; ad fuctioig referral systems for complex cases. Esurig that wome ca deliver with a skilled attedat cotributes to overall decreases i materal mortality by supportig wome through pregacy, delivery ad the postpartum period. 10,11 It also fills shortages i 12, 13 the health workforce. I selectig these two idicators, we also cosidered the availability of comparable, highquality atioal data. For more iformatio o the selectio of all the Idex idicators, refer to the Methodology o page 67. I 28 I A REPRODUCTIVE HEALTH INDEX

32 must support wome i beig able to access cotraceptive services to space births, receive quality ateatal care, deliver i a respectful eviromet with skilled persoel, access life-savig medicies i case of complicatios ad receive proper postpartum couselig ad care. Sustaied, log-term improvemets i materal health rely o explicit commitmets to wome s health, which are the supported with fiacial ad huma resource ivestmets i the health system. TRENDS AND HIGHLIGHTS Available ad accessible cotraceptive optios eable wome to time ad space their pregacies, which has a sigificat impact o reducig risk of materal death. Vietam (Idex Score: 77.2/100) reached the Milleium Developmet target of a 75 percet reductio i materal deaths; such tremedous gais i materal health are associated with the coutry s moder cotraceptive prevalece rate of 68.5 percet. 14,15 Despite the critical ature of ateatal care, globally oly 51 percet of wome receive at least four ateatal visits durig their pregacies. 16 I compariso, i the majority of coutries (76 percet) scorig i the high or mid-high category o the Idex, 60 percet or more of wome received at least four ateatal visits. Coutries scorig i the low category o the Idex, with the exceptio of Guiea, were all below the global average of 51 percet of wome receivig four ateatal visits. Wome who give birth without a skilled attedat equipped to recogize ad respod to complicatios face a greater risk of ot receivig life-savig drugs. For example, Chad (Idex Score: 25.5/100), the lowest raked coutry o the Idex, had a MMR of 980 materal deaths per 100,000 live births i 2013 (a MMR greater tha 300 materal deaths per 100,000 live births is cosidered high). 17 Oly 16.6 percet of births i Chad are atteded by skilled health persoel. Although Chad raks lowest overall o the Idex, it is ot the lowest rakig coutry i terms of this idicator percetage of births atteded by skilled health persoel. I Ethiopia, oly 10 percet of births are atteded by a skilled birth attedat. RIGHTS AND RESULTS I 29 I

33 percet of essetial materal ad ewbor health services. 19 Ivestmet i midwives has reaped sigificat beefits. For example, Idoesia (Idex Score: 49.8/100) developed a village midwife program that icluded preservice traiig ad deploymet of midwives to health facilities ad idepedetly at the village level. 20 The greater deploymet of midwives i Idoesia, particularly at the facility level, has bee associated with icreases i facility births ad deliveries with a skilled attedat. 21 Similarly Cambodia (Idex Score: 69.5/100) has see tremedous declies i materal mortality. Icreasig traiig ad utilizatio of midwives has cotributed to Cambodia s success. For more iformatio o Cambodia s materal health trasformatio, see the Risig Star box o page 32. Ulike several other idicators that appear i the Idex, percetage of births atteded by skilled health persoel does ot show a direct associatio with a high overall Idex score. Coutries cotiue to struggle with esurig that facilities desigated as Basic Emergecy Obstetric Care facilities ad Comprehesive Emergecy Obstetric Care facilities are actually able to provide the full suite of required services or sigal fuctios. However, i Malawi (Idex Score: 50.9/100) oe study foud 100 percet of its Comprehesive Emergecy Obstetric Care facilities were cosidered fully fuctioal. 18 Availability of fuctioal emergecy obstetric care udoubtedly cotributed to Malawi s declies i materal mortality from 1990 to i Withi well-equipped eablig eviromets, traied midwives who are regulated to iteratioal stadards ca provide 87 ACTIONS FOR HELPING WOMEN SAFELY THROUGH PREGNANCY, CHILDBIRTH AND THE POSTPARTUM PERIOD Provide uiversal access to cotraceptive iformatio, services ad supplies: Wome ad couples eed access to cotraceptive iformatio ad methods to realize their right to decide if ad whe to have childre. I additio, pregacies that are healthily spaced (at least two years betwee last birth ad ext pregacy) result i healthier outcomes for wome ad their childre. I 30 I A REPRODUCTIVE HEALTH INDEX

34 Eable access to adequate ateatal coverage: Icreased ateatal coverage helps wome prevet ad maage pregacy complicatios. I additio to screeig for materal complicatios, ateatal visits are a importat opportuity to provide itegrated services. Lowerig service costs to decrease fiacial limitatios ad usig commuitybased mobilizatio efforts to reach wome i rural ad remote commuities have bee effective i expadig the reach of materal health coverage. Trai ad deploy skilled birth attedats to perform deliveries: Skilled birth attedats may iclude urses, midwives ad doctors. Whe skilled birth attedats receive effective traiig i skills eeded to maage ucomplicated pregacies ad refer complicated deliveries to high levels of care, they save wome s lives. Skilled birth attedats are most effective whe supported with proper educatio, regulatio ad referral systems. Esure facilities ca effectively maage complicatios ad provide emergecy care: Skilled birth attedats aloe reduce eoatal deaths by 20 percet; the additio of basic emergecy obstetric care could double that impact. 22 Havig a effective referral system to a facility that is equipped ad able to provide emergecy obstetric care is critical to savig wome s lives ad prevetig materal morbidity due to delivery-related emergecies. Ivest i the availability ad accessibility of quality, life-savig drugs: Use of three iexpesive drugs oxytoci, misoprostol ad magesium sulfate ca help prevet ad treat post-partum hemorrhage ad hypertesio, two of the leadig causes of materal deaths. Icreasig the availability of these essetial medicies by: 1) esurig their iclusio i cliical guidelies ad atioal drug lists; 2) esurig facilities are adequately stocked to meet demad; ad 3) esurig health professioals are traied ad able to refer cases to facilities that admiister these critical drugs will cotiue to decrease the umber of materal deaths. 23,24 The availability of quality materal health supplies also requires a well-fuctioig supply chai that esures these drugs remai effective from procuremet to patiet. RIGHTS AND RESULTS I 31 I

35 RISING STAR CAMBODIA As a regio, Asia has made sigificat strides i health outcomes for wome ad childre. However, there are disparities across coutries i the regio. I the otso-distat past, Cambodia had health statistics similar to may coutries i sub-sahara Africa. I 1990, Cambodia s MMR was 1,200 materal deaths per 100,000 live births higher tha the ratio i Bei, Burkia Faso, Democratic Republic of Cogo ad Haiti. 25 Startig i the mid-1990s, the Cambodia govermet ad doors bega icreasig ivestmets i health. 26 A commitmet to materal health emerged aroud 2005, as evideced by icreased traiig of providers, the itroductio of active maagemet of the third stage of labor as stadard practice, safe abortio services, ad the deploymet of midwives to health uits. 27 I 2005, the Miister of Health expressed support specifically for midwife-based materal health strategies. 28 As of 2010, 71 percet of births i Cambodia were atteded by skilled health persoel. Accordig to the World Health Orgaizatio, Cambodia is o track i terms of progress i improvig materal health relative to MDG 5.A ad the govermet is focused o a recetly developed Fast Track Iitiative Road Map for Reducig Materal ad MATERNAL MORTALITY RATIO (MMR) Cambodia s Reductio i Materal Mortality 1,200 1, Newbor Mortality. This iitiative focuses o emergecy obstetric care, skilled birth attedace, family plaig, safe abortio, removal of fiacial barriers ad materal death surveillace ad respose to accelerate further progress o materal health % reductio betwee 1990 ad YEAR Source: World Health Orgaizatio Treds i Materal Mortality: 1990 to 2013 Estimates by WHO, UNICEF, UNFPA, The World Bak ad the Uited Natios Populatio Divisio. Geeva: WHO I 32 I A REPRODUCTIVE HEALTH INDEX

36 Edotes 1 World Health Orgaizatio (WHO), Uited Natios Childre s Fud (UNICEF), UN Populatio Fud (UNFPA), The World Bak ad the UN Populatio Divisio. Treds i Materal Mortality: 1990 to Geeva: WHO, Refrew, M, et al. Midwifery ad quality care: fidigs from a ew evidece-iformed framework for materal ad ewbor care. The Lacet, 384(9948): , U.S. Agecy for Iteratioal Developmet (USAID). HTSP 101: Everythig you wat to kow about healthy timig ad spacig of pregacy. htsp101.pdf 4 World Health Orgaizatio. Treds i Materal Mortality: 1990 to 2013 Estimates by WHO, UNICEF, UNFPA, The World Bak ad the Uited Natios Populatio Divisio. Geeva: WHO, WHO Materal Morbidity Workig Group. Measurig Materal Health: Focus o Materal Morbidity. Bulleti of the World Health Orgaizatio, 91: Geeva: WHO, Ibid. 7 Hussei, J, L Kaguru, M Asti, ad S Mujaja. The Effectiveess of Emergecy Obstetric Referral Itervetios i Developig Coutry Settigs: A Systematic Review. PLos Med 9(7): e , Freedma, L. 23 Jue Disrespect ad abuse of wome i childbirth: challegig the global quality ad accoutability agedas. The Lacet, 384(9948): e42 44, UNICEF. Materal Health: Ateatal Care: Curret Status ad Progress Refrew, M, et al. Midwifery ad quality care: fidigs from a ew evidece-iformed framework for materal ad ewbor care. The Lacet, 384(9948): , Law, J. et al. 20 Every Newbor: Progress, priorities ad potetial beyod survival. The Lacet, 384(9938): , Refrew, M, et al. Midwifery ad quality care: fidigs from a ew evidece-iformed framework for materal ad ewbor care. The Lacet, 384(9948): , Law, J. et al. 20 Every Newbor: Progress, priorities ad potetial beyod survival. The Lacet, 384(9938): , UNFPA. Materal death halved i 20 years, but faster progress is eeded, UN Developmet Programme. World Cotraceptive Use Coutry Data Survey-Based.\, UNICEF. Global Databases: Ateatal care coverage: at least four visits Percetage WHO, UNICEF, UNFPA, The World Bak ad the UN Populatio Divisio. Treds i Materal Mortality: 1990 to Geeva: WHO, Ameh, C et al. 6 December Status of Emergecy Obstetric Care i Six Developig Coutries Five Years Before the MDG Targets for Materal ad Newbor Health. Plos Oe, December 6, DOI: World Health Orgaizatio Edig Prevetable Materal Mortality Workig Group. Strategies toward edig prevetable materal mortality (EPMM). Draft paper reproductivehealth/topics/materal_periatal/strategies_epmm_commet.pdf?ua=1 20 Va Lerberghe, W et al. Coutry experiece with stregtheig of health systems ad deploymet of midwives i coutries with high materal mortality. The Lacet, 384(9949): , Ibid. 22 Zulfiqar, B et al. Ca available itervetios ed prevetable deaths i mothers, ewbor babies, ad stillbirths, at what costs? The Lacet, 384(9940): , WHO. WHO Model List of Essetial Medicies. Geeva: WHO Say, L et al. Global Causes of Materal Death: A WHO Systematic Aalysis. Lacet Global Health (2): e323-33, WHO, UNICEF, UNFPA, The World Bak ad the UN Populatio Divisio. Treds i Materal Mortality: 1990 to Geeva: WHO, Va Lerberghe, W et al. Coutry experiece with stregtheig of health systems ad deploymet of midwives i coutries with high materal mortality. The Lacet, 384(9949): , Ibid. 28 Ibid. 29 WHO, UNICEF, UNFPA, The World Bak ad the UN Populatio Divisio. Treds i Materal Mortality: 1990 to Geeva: WHO, RIGHTS AND RESULTS I 33 I

37 PREVENTING AND TREATING STIs, INCLUDING HIV/AIDS I 34 I A REPRODUCTIVE HEALTH INDEX

38 Fulfillig a woma s sexual ad reproductive health ad rights (SRHR) requires that she have access to high-quality reproductive health iformatio, services ad supplies i order to prevet sexually trasmitted ifectios (STIs). If diagosed with a STI, all wome must have access to safe ad effective optios for treatmet. Failure to protect wome s SRHR results i icreased vulerability to STIs. Each day, more tha oe millio people acquire a o-hiv STI. I additio to the immediate cosequeces of the ifectio itself, STIs carry a rage of potetial egative effects, icludig icreased risk of HIV, pelvic iflammatory disease, cervical cacer, ufavorable pregacy outcomes ad ifertility. 1 Ifected idividuals are also frequetly stigmatized. Stigma ad discrimiatio ca have harmful social ad psychological effects o those ifected, leadig to a poorer quality of life. Similarly, stigma ad discrimiatio ca create barriers to the access of prevetio, treatmet ad support services. 2 Surveillace of o-hiv STIs is weak compared to that of HIV/AIDS ad eeds to be ehaced i order to effectively assess, moitor ad desig appropriate programs. However, the curret data available show the umber of ew cases of curable STIs * rose from 448 millio i 2005 to 499 millio i 2008, despite the existece of simple ad cost-effective itervetios. The chage from 2005 to 2008 reflects a icrease i the icidece of goorrhea by 21 percet, trichomoiasis by 11 percet ad chlamydia by four percet. The icidece of syphilis showed o chage. 3 *Goorrhea, chlamydia, syphilis, ad trichomoiasis. I 2013, a estimated 35 millio people were livig with HIV, ad early 1.5 millio people died of AIDS-related illesses worldwide. Sub-Sahara Africa is disproportioately affected by the epidemic, accoutig for early 71 percet of ew ifectios i HIV ca affect ayoe, but socially margialized idividuals are at a higher risk of ifectio ad are thereby cosidered key populatios. Prevalece amog ijectig drug users, sex workers ad me who have sex with me is repeatedly reported as higher tha amog the geeral populatio. Wome of reproductive age are particularly at risk, with early 1,000 youg wome RIGHTS AND RESULTS I 35 I

39 ifected with HIV each day. 4 Accordigly, public health programs ad policies must be drive by huma rights, with ivestmet i trasformig detrimetal geder orms. The o-crimializatio of HIV is vital to protectig ad meetig the eeds of key populatios. 5 Providig wome with iformatio ad couselig through itervetios like comprehesive sexuality educatio, safe sex couselig ad the promotio of codoms is a key method of prevetio. 6 Whe equipped with accurate ad relevat iformatio, wome are better positioed to make choices that reduce their risk ad protect them from STIs. Outside of abstiece, codoms, both male ad female, offer the most powerful form of protectio agaist STIs, icludig HIV. 7 Ufortuately, the availability of barrier methods aloe is ot sufficiet. Power dyamics ad geder iequalities may limit a woma s ability to egotiate codom use with her parter. 8 It is, therefore, essetial that ivestmets be made i female-cotrolled methods. If a woma is diagosed with a STI, she must have access to safe, effective, highquality ad affordable optios for treatmet. While effective treatmet optios exist for STIs, substatial roadblocks cotiue to impede access to quality services ad egatively impact wome s SRHR. STI ad HIV services are ofte ot itegrated ito routie health services, such as primary care or family plaig, makig it hard for wome + A CLOSER LOOK INDICATORS FROM THE INDEX May factors ifluece the prevetio ad treatmet of STIs, icludig HIV/AIDS. For our Idex, we selected three idicators focused o prevetio ad treatmet as measures of this dimesio of SRHR. They are: percetage of wome age with kowledge of HIV prevetio methods (usig codoms ad limitig sexual itercourse to oe uifected parter); percetage of wome with a STI or STI symptoms who sought advice or treatmet from a cliic, hospital, private doctor or other health professioal; ad percetage of wome receivig atiretroviral therapy amog wome eligible. The first (percetage of wome age with kowledge of HIV prevetio methods) was chose because access to high-quality, reproductive health iformatio, services ad supplies is a prerequisite for prevetig STIs, icludig HIV. The other two (percetage of wome with a STI or potetial STI symptoms who sought advice or treatmet from a cliic, hospital, private doctor or other health professioal ad atiretroviral coverage amog wome eligible) are idicative of wome s access to safe, effective high-quality treatmet upo diagosis of a STI or HIV/AIDS. Give that proper educatio ad couselig ca ehace a woma s ability to idetify symptoms ad subsequetly seek treatmet, the STI idicator ca also represet access to high-quality iformatio. Ad both the seekig treatmet for a STI ad atiretroviral therapy coverage idicator cotribute to prevetio. Successful STI treatmet by a health professioal may reduce the likelihood of trasmissio, particularly for curable STIs, ad atiretroviral coverage is recogized for its ability to prevet HIV ifectios, particularly amog pregat wome, youg childre ad key high-risk populatios. I selectig these three idicators, we also cosidered the availability of comparable, high-quality atioal data. For more iformatio o the selectio of all the Idex idicators, refer to the Methodology o page 67. I 36 I A REPRODUCTIVE HEALTH INDEX

40 to seek treatmet. 9 Capacity costraits further ihibit access to high-quality, effective services as coutries face a lack of properly traied persoel, laboratory capacity, screeig for asymptomatic ifectios ad appropriate medicie supplies. 10 Furthermore, aside from HIV, STIs are ot viewed as a priority for public health, ad, cosequetly, prevetio ad treatmet programs are ofte uderfuded ad lack appropriate resources. 11 Though challeges persist i the fight agaist HIV/AIDS, progress is beig made at a global scale. Atiretroviral therapy typically comprised of three or more atiretroviral drugs is beig used successfully to suppress HIV ad prohibit its progressio. 12 Globally, the umber of ew HIV ifectios has decreased from 3.4 millio i 2001 to 2.1 millio i 2013, a marked 38 percet decrease. TRENDS AND HIGHLIGHTS While wome accout for about half of all adults livig with HIV globally, they accout for early 60 percet i sub-sahara Africa. I this regio, ifectio rates amog youg wome are twice that of youg me. 13 Kowig how to prevet HIV is vital to reducig the umber of ew ifectios. Overall, amog the coutries scored o the Idex, whe asked about effective methods of HIV prevetio, approximately 60 percet of wome ca properly idetify: a) limitig sex to oe uifected parter; ad b) codom use. Amog the top 17 coutries i the Idex (which make up the high ad midhigh categories), the proportio of wome with comprehesive kowledge is drastically higher. I these coutries, a average of 75 percet of wome idetified both prevetio methods. Over 85 percet of wome demostrate comprehesive kowledge of HIV prevetio i Ukraie, Swazilad, ad Cabo Verde coutries raked i the top te o the Idex. Coversely, amog coutries i the low category of the Idex, the proportio of wome with comprehesive kowledge of HIV prevetio averages 40 percet ad is as low as 19.5 percet i Pakista (Idex Score: 36.7/100). Kowledge of HIV prevetio ca be bolstered through comprehesive sexuality educatio for youth. Keya (Idex Score: 62.6/100), where close to 71 percet of wome demostrated comprehesive kowledge of prevetio, has worked to icrease kowledge through programs such as the Nyeri Youth Health Project (for more iformatio, see page 39). A woma s ability to seek advice or treatmet from a health professioal for a STI or STI-related symptoms differs amog coutries i the Idex. Overall, a average of about 54 percet of wome reported seekig advice or treatmet from a health professioal. However, coutries raked i the high ad mid-high categories of the Idex have a markedly higher average of approximately 64 percet. I fact, i three of the top six coutries o the Idex (Swazilad, Cabo Verde ad Republic of Moldova) more tha 74 percet of wome with a STI or STI-related symptoms sought advice or treatmet from a health professioal. The opposite tred is see amog coutries at the bottom of the Idex. Amog the coutries i the low category o the Idex, a average of about 39 percet of wome reported seekig advice or treatmet from a health professioal. 14

41 May coutries have see HIV icidece drop by more tha 50 percet betwee 2001 ad Icreasig atiretroviral coverage for wome ca cotribute to a decrease i HIV icidece by prevetig motherto-child trasmissio. I Ghaa (Idex Score: 64.9/100), the umber of ew HIV ifectios has decreased by 43 percet sice Ghaa s impressive reductio i ew ifectios is due i large part to their success i prevetig mother-to-child-trasmissio through expaded atiretroviral therapy coverage for pregat wome livig with HIV. 17 The risk of mother-to-child-trasmissio decreased from 31 percet i 2009 to ie percet i 2012, coicidig with a icrease i coverage amog pregat wome livig with HIV from 32 percet i 2009 to over 90 percet i I 38 I A REPRODUCTIVE HEALTH INDEX Ufortuately, World Health Orgaizatio (WHO) estimates for low- ad lower-middleicome coutries show that o average, just over half of the HIV-positive wome eligible received the atiretroviral therapy treatmet they eeded i Atiretroviral therapy coverage amog wome varies greatly by coutry, with levels below two percet i Madagascar (Idex Score: 42.1/100) compared to above 95 percet i Cabo Verde (Idex Score: 73.0/100) ad Guyaa (68.9/100). 19 ACTIONS FOR PREVENTING AND TREATING STIS, INCLUDING HIV Desig programs ad policies cetered o huma rights: Coutries must address the SRHR of all people i a way that is sesitive to ad iclusive of key at-risk populatios. The o-crimializatio of HIV is critical to meetig the eeds of key populatios ad esurig they have access to prevetio tools ad treatmet. 20 Elimiate the stigma of STIs, icludig HIV/ AIDS: Icreasig kowledge ad awareess withi the health system as well as amog the geeral populatio via traiig, educatio ad literacy programs ca help reduce stigma ad discrimiatio. 21 Provide access to high-quality comprehesive sexuality educatio: Icreasig access to iformatio through mechaisms like comprehesive sexuality educatio is a vital pathway to prevetio. I additio to beig a key compoet of prevetio, educatio ad couselig ca advace a woma s capacity to idetify symptoms of STIs ad, cosequetly, improve the likelihood she will pursue care from a qualified health professioal. 22 Make barrier methods available as a optio for those who are sexually active: High-quality ad affordable barrier methods must be cosistetly available whe ad where they are eeded. To facilitate this, codoms should be promoted ad distributed i both cliical ad ocliical outlets with supplemetal commuitybased distributio to reach key populatios. Distributio i traditioal settigs must ivolve providers who have bee traied to respect the uique sexual ad reproductive health eeds of youth ad esure codoms are available to them. 23

42 SEXUALITY EDUCATION: NYERI YOUTH HEALTH PROJECT IN KENYA Whe youg people are provided with accurate ad relevat iformatio, they are better prepared to make choices that improve their health ad protect them from STIs, icludig HIV. 24 The Nyeri Youth Health Project i Keya is a strog example of a culturally sesitive, commuity-based sexual health program desiged to decrease risky sexual behaviors ad delay the iitiatio of sex. The project employed youg, well-respected parets from the commuity, kow as atiri, i accordace with local traditios. The atiri were traied to be frieds of youth (FOYs) who could guide youg people o issues related to sexuality. FOYs were traied usig a sexual educatio curriculum called Life Plaig Skills for Youg People i Keya that covered thigs like adolescet developmet, pregacy, STIs, HIV, detrimetal traditioal practices ad child rights. The FOYs worked with youth idividually ad i groups ad also egaged adults i the commuity to foster a positive eviromet i which the sexual health issues of youth could be addressed. I partership with local schools, the FOYs educated teachers to ehace their commuicatio with studets about sexual health. Local health professioals were also traied o how to provide youth-friedly sexual ad reproductive health (SRH) services so that FOYs could refer youg people to these traied providers. 25 Project evaluatio results showed umerous favorable outcomes, icludig delayed iitiatio of sex, icreased codom use, reduced umber of sexual parters, icreased commuicatio with parets ad adults about SRH ad a icrease i abstiece amog previously sexually active youth. This project reiforces existig kowledge about the success ad importace of comprehesive sexuality educatio programs. However, like may other promisig programs, it was implemeted may years ago. The project eded i This sigals a cotiued eed for coutries ivest i log-term programs that ca sustai successful itervetios like those used i the Nyeri Youth Health Project. Ivest i female-cotrolled methods: I cocert with strategies to elimiate geder iequality, ivestmets must be made i the research ad desig of female-cotrolled methods of protectio, such as microbicides. Microbicides are topical compouds or suppositories that ca protect agaist STIs, icludig HIV, ad i some cases also serve as a cotraceptive. The developmet of a dual-use method like microbicides could empower wome to protect themselves without egotiatio with their parters. 26 Ivest i buildig the capacity of health systems withi coutries to esure effective service delivery: Fudig from govermets ad doors is icreasigly chaeled to the etire health sector as opposed to particular health projects. This sector-wide approach ca leave historically eglected issues like STIs with dimiished fudig. It is, therefore, essetial that coutry govermets prioritize the prevetio ad treatmet of STIs withi the health sector s ageda. 27 Scale up atiretroviral therapy: As a treatmet mechaism for HIV, atiretroviral therapy has resulted i drastic reductios i death ad sufferig, particularly whe used i the early RIGHTS AND RESULTS I 39 I

43 stages of the virus. I additio to success i treatig HIV, atiretroviral drugs have bee recogized for their efficacy i prevetig trasmissio. Accordigly, i 2013 WHO expaded its recommedatio to iclude the use of atiretrovirals for prevetio, especially i pregat wome, youg childre ad key high-risk populatios. 28 Itegrate STI ad HIV/AIDs programs with other health ad developmet iitiatives: Visits to health facilities come with costs to both the idividual woma ad the health system. Maximizig the beefits of these visits through itegratio ca icrease uptake of services ad improve program efficiecy. 29 RISING STAR MALAWI Malawi experieced a declie i HIV prevalece from 16.5 percet i 2003 to 10.3 percet i 2013, alogside a 69 percet decrease i the umber of ew HIV ifectios. The success of Malawi s HIV respose to date stems largely from the scale-up of atiretroviral therapy coverage i cojuctio with other resourceful itervetios. 30 I 2011, Malawi s Miistry of Health (MOH) implemeted a iovative strategy called Optio B+ that made all HIV-positive pregat ad breastfeedig wome eligible for lifelog atiretroviral therapy. 31 I order to effectively implemet Optio B+, the MOH itegrated atiretroviral therapy with materal ad child health services i primary care facilities, traied urses to prescribe the drugs, ad used a sigle atiretroviral treatmet regime for both o-pregat ad pregat adults. The simplificatio of the regime resulted i icreased kowledge ad familiarity of treatmet amog health workers, alog with a more efficiet procuremet process. 32 Malawi has also worked to icrease HIV testig ad couselig usig iovative approaches to reduce the fear ad stigma that ca be associated with testig. Mobile testig ad couselig vas, door-to-door testig ad a itesive aual week-log campaig have helped Malawi icrease access to HIV testig ad couselig services. 33 Other iovative itervetios have demostrated promisig results i Malawi. A cash trasfer program evaluated by the World Bak offered paymets to families of youg girls if they stayed i school. Results show a 60 percet decrease i HIV icidece ad a 75 decrease i the icidece of herpes simplex virus Type 2 amog participats. 34 These strategies are just some of the itervetios that eabled Malawi to make remarkable progress i the fight agaist HIV. As a result, atiretroviral therapy coverage amog pregat wome rose from 26 percet i 2010 to 79 percet i 2013 ad the umber of ew HIV ifectios for Malawi overall dropped by more tha 40 percet durig the same time period. 35,36 I 40 I A REPRODUCTIVE HEALTH INDEX

44 Edotes 1 World Health Orgaizatio (WHO). Sexually Trasmitted Ifectios (STIs). Geeva: WHO, The Joit Uited Natios Programme o HIV/AIDS (UNAIDS). The Gap Report Geeva: UNAIDS, WHO. Sexually Trasmitted Ifectios (STIs). Geeva: WHO, UNAIDS. The Gap Report Geeva: UNAIDS, UNAIDS. Crimializatio of HIV Trasmissio. Geeva: UNAIDS, WHO. Sexually Trasmitted Ifectios (STIs). Geeva: WHO, Ibid. 8 Joit Uited Natios Programme o HIV/AIDS. Resource Pack o Geder ad HIV/AIDS. Geeva: UNAIDS, WHO. Sexually Trasmitted Ifectios (STIs). Geeva: WHO, Ibid. 11 Ibid. 12 WHO. HIV Treatmet ad Care UNAIDS. The Gap Report Geeva: UNAIDS, ICF Iteratioal Demographic ad Health Surveys. Calverto, MD: ICF Iteratioal, UNAIDS. The Gap Report Geeva: UNAIDS, Ibid. 17 UNAIDS Regioal Support Team for West ad Cetral Africa. Ghaa Makes Impressive Strides i HIV Natioal Respose, December 9, UNAIDS. Global Report: UNAIDS Report o the Global AIDS Epidemic Geeva: UNAIDS, UNAIDS. Crimializatio of HIV Trasmissio. Geeva: UNAIDS, UNAIDS. The Gap Report Geeva: UNAIDS, WHO. Sexually Trasmitted Ifectios (STIs). Geeva: WHO, UNAIDS. Resource Pack o Geder ad HIV/AIDS. Geeva: UNAIDS, UNESCO & UNFPA. Youth ad Comprehesive Sexuality Educatio. UNESCO & UNFPA Advocates for Youth. Sciece & Success i Developig Coutries: Holistic Programs that Work to Prevet Tee Pregacy, HIV & Sexually Trasmitted Ifectios. AFY, WHO. Microbicides WHO. Global Strategy for the Prevetio ad Cotrol of Sexually Trasmitted Ifectios: WHO, WHO. HIV Treatmet ad Care Populatio Referece Bureau. Supportig the Itegratio of Family Plaig ad HIV Services. Washigto, DC: PRB, Govermet of Malawi. Global AIDS Respose Progress Report (GARPR)Malawi Progress Report for Govermet of Malawi, Ceter for Disease Cotrol ad Prevetio. Impact of a Iovative Approach to Prevet Mother-to-Child Trasmissio of HIV Malawi. Mortality & Morbidity Weekly Report, 62(8), Govermet of Malawi. Global AIDS Respose Progress Report (GARPR) Malawi Progress Report for Govermet of Malawi, Govermet of Malawi. Malawi HIV ad AIDS Moitorig ad Evaluatio Report: , Uited Natios Geeral Assembly Special Sessio Coutry Progress Report. Govermet of Malawi, Kurth, A et al. Combiatio HIV Prevetio: Sigificace, Challeges, ad Opportuities. Curr HIV/AIDS Rep. 8(1): 62 72, UNAIDS. AIDSifoOlie Database. UNAIDS, UNAIDS. The Gap Report Geeva: UNAIDS, RIGHTS AND RESULTS I 41 I

45 ENABLING ENVIRONMENT FOR SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS I 42 I A REPRODUCTIVE HEALTH INDEX

46 Fulfillig the sexual ad reproductive health ad rights (SRHR) of wome depeds ot oly a strog health system, but o a eablig eviromet that empowers wome to make iformed decisios about their ow health. A eablig eviromet is oe that, through coected ad mutually reiforcig factors, fosters ad protects a woma s autoomy ad cocurretly removes threats to her decisio-makig power. A eablig eviromet elimiates the gaps betwee me ad wome, esurig equal access to social, ecoomic, ad political opportuities. 1 I a eablig eviromet, wome are free from violece, have cotrol over their sexual ad reproductive health, are awarded equal rights i property owership ad iheritace, ad have equal opportuity to be amog the political actors shapig istitutios ad policies. Ufortuately, geder iequality ad geder biases are ofte guided by deeply pervasive social orms, the scope ad itesity of which vary both amog ad withi coutries. These orms ca have a tremedous impact o a woma s mobility, represetatio i govermet ad power to make decisios for herself. Harmful social orms ca also foster uequal power relatioships withi households ad societies, placig decisiomakig outside of a woma s cotrol. Child marriage is oe factor that substatially restricts ad udermies autoomy ad detracts from a eablig eviromet. The practice both deprives girls of their right to make sigificat life decisios ad limits their opportuities to egage i areas that otherwise positively impact autoomy, like educatio ad icome earig. Child marriage deies girls their ability to choose for themselves whe ad whom they marry alog with whe ad how may childre they have. 2 Oce married, girls are ofte expected to become pregat quickly ad are likely to feel uable to refuse sex aother fudametal loss of autoomy. 3 Furthermore, adolescet wives are more vulerable to violece ad are proe to dimiished educatioal opportuities due to early pregacy. 4 The loss of educatio is I 43 I A REPRODUCTIVE HEALTH INDEX

47 also a crucial loss for a woma s autoomy, as educatioal opportuities provide wome ad girls with the kowledge ad skills they eed to make iformed decisios ad ca help trasform geder orms that limit wome s opportuities. Eve where geder orms are restrictive, better-educated wome are more frequetly able to exercise decisio-makig power. 5 + A CLOSER LOOK INDICATORS FROM THE INDEX Wome with more educatio are poised to egage i paid employmet, which i additio to icreasig family icome ad overall productivity, ehaces their decisiomakig power. 6 A woma s ability to ear her ow icome ot oly improves her bargaiig power withi her household but also icreases her ability to grow her idividual assets. The accumulatio of May factors ifluece a eablig eviromet. For our Idex, we selected two idicators focused o drivers of autoomy to measure this dimesio of SRHR. They are: percetage of wome age who were ot married or i uio before age 18; ad percetage of curretly married wome age who participate i all surveyed household decisios either by themselves or joitly with their husbad. The first percetage of wome age who were ot married or i uio before age 18 was chose because it ot oly reflects a woma s power to make critical decisios about the formatio of her family but also impacts other outcomes ad elemets of autoomy. Because a higher Idex score represets a more positive status for wome, this idicator was calculated by subtractig the prevalece of child marriage from 100 to reflect the percetage of wome who were ot married or i uio before age 18. The other percetage of curretly married wome age who participate i all surveyed household decisios either by themselves or joitly with their husbad is idicative of woma s ability to make choices withi her household ad withi her marriage, while also reflectig societal orms that ca shape autoomy. I selectig these two idicators, we also cosidered the availability of comparable, highquality atioal data. For more iformatio o the selectio of all the Idex idicators, refer to the Methodology o page 67. idepedet assets allows wome to cope with uexpected situatios, to ivest i ad grow her icome ad opportuities for employmet ad to leave a marriage should she choose to. 7 Decisio-makig power withi her household ca be idicative ot oly of the level of cotrol a woma has over her eviromet but also of existig geder orms. Social orms have a eormous impact o people s values ad behavior, ifluecig power dyamics withi households ad society at large. Accordigly, gais made via laws, access to services, educatio ad icome ca be costraied by pervasive social orms. 8 TRENDS AND HIGHLIGHTS More tha 700 millio wome alive today were married before they tured 18, ad about 250 millio were married before their 15 th birthday. The practice of child marriage reflects geder iequalities ad the social orms that sustai discrimiatio agaist girls. 9 Child marriage is most prevalet i South Asia ad sub-sahara Africa but differs amog coutries i the Idex. Overall, amog coutries i the Idex, a average of about 30 percet of wome age were married or i uio before they tured 18. I 44 I A REPRODUCTIVE HEALTH INDEX

48 However, coutries raked i the high ad mid-high categories of the Idex have a markedly lower average of approximately 19 percet. I fact, i the top four coutries o the Idex, less tha 10 percet were married before 18. However, the opposite tred is see amog coutries at the bottom of the Idex. I three of the four coutries at the bottom of the Idex (Bagladesh, Niger ad Chad), a average of about 70 percet of wome were married before 18. While the prevalece of child marriage varies amog coutries, aalysis of data from Demographic ad Health Surveys reveals a commo theme educatioal opportuities are dimiished amog child brides compared to girls who delay marriage util after 18. Geder disparities are pervasive o a global scale where wome represet less tha 22 percet of parliametarias worldwide. I 2013, 128 coutries treated me ad wome differetly uder the law i at least oe istace. The differeces raged from obstacles for wome obtaiig idetificatio cards to costraits o owig property ad obtaiig employmet. Twety-eight coutries had te or more differeces i the way wome were treated uder the law compared to me. 10 Geder iequalities ad power dyamics are evidet ot oly i society at large but withi households as well. Overall, amog the coutries scored o the Idex, a average of approximately 49 percet of wome participate i all surveyed household decisios, either aloe or joitly with their husbads. Amog the HIGHEST LEVEL OF EDUCATION ATTENDED BY WOMEN AGE 20-24: comparig COMPARING THOSE those who WHO were WERE married MARRIED by BY to TO those THOSE who WHO were WERE ot NOT % of o-child brides ad child brides % of o-child brides ad child brides No-Child Brides Over 70 percet of o-child brides i Ukraie atteded school beyod the secodary level, compared to oly 38 percet of child brides NO EDUCATION NO EDUCATION PRIMARY PRIMARY UKRAINE NIGER SECONDARY SECONDARY HIGHER HIGHER I Niger, almost 96 percet of child brides had o educatio or did ot atted school beyod the primary level, compared to almost 69 percet of o-child brides. % of o-child brides ad child brides % of o-child brides ad child brides Child Brides I Vietam, over 80 percet of o-child brides atteded secodary school or higher, comparedto oly 46 percet of child brides. I Chad, about 95 percet of child brides had o educatio or did ot atted school beyod the primary level, compared to about 78 percet of o-child brides Source: ICF Iteratioal Demographic ad Health Surveys (various). Calverto, Marylad: ICF Iteratioal NO EDUCATION NO EDUCATION PRIMARY PRIMARY VIETNAM CHAD SECONDARY SECONDARY HIGHER HIGHER RIGHTS AND RESULTS I 45 I

49 top 17 coutries i the Idex (which make up the high ad mid-high categories), the proportio of wome who participate i all decisios is drastically higher, with a average of 65 percet. More tha 80 percet of wome participate i all household decisios i Ukraie, Armeia, Republic of Moldova, Cambodia ad Guyaa coutries raked i the top te o the Idex. Coversely, amog coutries i the low category of the Idex, the proportio of wome with household decisiomakig power averages at approximately 29 percet, ad is as low as ie percet i Mali (Idex Score: 39.1/100). Aalysis of data from Demographic ad Health Surveys shows household decisio-makig power is bolstered amog wome who ear their ow cash icome. ACTIONS FOR FOSTERING AN ENABLING ENVIRONMENT Elimiate child, early ad forced marriage: Policymakers must, at a miimum, pass ad eforce legislatio that establishes 18 as the legal miimum age of marriage. However, while policies are a importat first step, they aloe are ot sufficiet. Strog policies will oly be effective at protectig youg girls if they are fully implemeted ad eforced. I additio to legislatio o the miimum age of DESCISION MAKING POWER BY EMPLOYMENT STATUS % of wome who participate i all household decisios 100 Employed for cash 90 Employed, ot paid or paid i kid Not employed UKRAINE ARMENIA SWAZILAND PAKISTAN BANGLADESH NIGER TOP INDEX COUNTRIES BOTTOM INDEX COUNTRIES Source: ICF Iteratioal Demographic ad Health Surveys (various). Calverto, Marylad: ICF Iteratioal. I 46 I A REPRODUCTIVE HEALTH INDEX

50 marriage, policy ad program itervetios should be desiged to empower girls ad cofrot the drivers of early marriage. Programs i the poverty, educatio ad sexual ad reproductive health sectors should be coordiated to maximize their effectiveess. 11 Icrease access to formal educatio: Educatio should be provided free of charge to safeguard agaist fiacial barriers to access. Educatio should also be compulsory to icrease the likelihood girls will stay i school. Curricula should be developed that are relevat ad iclusive of girls ad the safety of schools stregtheed so that girls feel protected. It is essetial that schools do ot exclude girls who are married ad/ or pregat. Accordigly, alterative or oformal educatio programs should be available to accommodate a girl s uique circumstace. 12 Provide wome with the opportuity to ear their ow icome through participatio i the formal labor sector: Policies aimed at job creatio must also address barriers that prevet wome from accessig paid employmet, icludig lack of traiig, resposibilities as caretakers for their childre, access to credit ad gederbiased perceptios about wome s abilities. 13 Egage commuities to trasform harmful social orms that hider a woma s autoomy: Iformatio sharig that highlights alteratives to curret practices ca be a effective way of trasformig logstadig orms. Iitiatives that ecourage collective actio ad coordiated efforts ca help maximize impact. 14 To that ed, it is essetial to ivolve me, boys, elders ad commuity members i order to chage social orms that sustai harmful practices. Those with the power ad authority to support chage ca serve as effective champios for wome ad girls. 15 RIGHTS AND RESULTS I 47 I

51 PROMISING PROGRAM: INDIA 16 Idia, oe of the world s most populous coutries, has see drastic reductios i fertility i may of its states. However, a area collectively kow as BIMARU, which houses over 40 percet of the coutry s populatio, has ot experieced the same chage. Idia s progress i reproductive health, eve i states with lower fertility, is threateed by the uequal utilizatio of family plaig ad reproductive health services alog with early childbearig liked to child marriage. To address these challeges, Pathfider Iteratioal implemeted the PRACHAR program, which i Hidi meas to let people kow or to dissemiate. Desiged to improve the sexual ad reproductive health of adolescets ad youg couples, the project egaged all members of the commuity to shift orms aroud early marriage, childbearig ad barriers to sexual ad reproductive health services for youg people. The itervetio employed reproductive health traiigs for youth, cotraceptive couselig home visits for youg couples, group meetigs with male chage agets ad home visits with parets ad pregat females. Pathfider s program evaluatio foud that curret use of cotraceptio amog youg married couples icreased from four percet to 21 percet; age at first marriage icreased by 2.6 years to age 22; ad age at first birth was delayed by 1.5 years to age Buildig o its success to date, the program is curretly i its third implemetatio phase, where it is beig scaledup to the largest district i the state of Bihar. I this phase, Pathfider Iteratioal is workig with the Bihar govermet to icorporate PRACHAR s successful itervetios ito the state s health care system. Through this partership, govermet health workers will begi itegratig PRACHAR s approaches ito their daily activities. This critical govermet support is expected to icrease the program s reach ad impact. PRACHAR provides a example of a promisig program aimed at targetig some of the key factors that cotribute to a eablig eviromet. The program uses some of the fudametal strategies discussed i this chapter, icludig iformatio sharig with youg wome ad me, youg couples, parets ad ifluetial commuity members to trasform social orms ad icrease the uptake of reproductive health services. Though this program is a powerful example, it aloe caot guaratee a eablig eviromet for all wome ad girls i Idia. Coutries must employ a comprehesive, log-term approach that addresses all the compoets of a eablig eviromet, icludig formal educatio ad ecoomic opportuity. I 48 I A REPRODUCTIVE HEALTH INDEX

52 Edotes 1 Uited Natios Populatio Fud (UNFPA). State of World Populatio 2005: The Promise of Equality. New York: UNFPA, The World Bak. World Developmet Report 2012: Geder Equity ad Developmet. Washigto, DC: The World Bak, UNFPA. Marryig Too Youg. New York: UNPFA, Uited Natios Childre s Fud (UNICEF). State of the World s Childre 2009: Materal ad Newbor Health. New York: UNICEF, The World Bak. Voice ad Agecy: Empowerig Wome ad Girls for Shared Prosperity. Washigto, DC: The World Bak, Uited Natios Populatio Fud. State of World Populatio 2005: The Promise of Equality. New York: UNFPA, The World Bak. World Developmet Report 2012: Geder Equity ad Developmet. Washigto, DC: The World Bak, Ibid. 9 UNICEF. Edig Child Marriage: Progress ad Prospects. New York: UNICEF, The World Bak. Voice ad Agecy: Empowerig Wome ad Girls for Shared Prosperity. Washigto, DC: The World Bak, UNFPA. Marryig Too Youg. New York: UNPFA, Ibid. 13 The World Bak. Voice ad Agecy: Empowerig Wome ad Girls for Shared Prosperity. Washigto, DC: The World Bak, The World Bak. World Developmet Report 2012: Geder Equity ad Developmet. Washigto, DC: The World Bak, The World Bak. Voice ad Agecy: Empowerig Wome ad Girls for Shared Prosperity. Washigto, DC: The World Bak, Pathfider Iteratioal. PRACHAR: Advacig Youg People s Sexual ad Reproductive Health ad Rights i Idia. Watertow, MA: Pathfider, RIGHTS AND RESULTS I 49 I

53 I 50 I A REPRODUCTIVE HEALTH INDEX IN FOCUS: EQUITY

54 Despite decades of progress i expadig sexual ad reproductive health (SRH) iformatio, services ad supplies, certai groups cosistetly face health iequalities. Poor, less-educated, youg, rural ad margialized groups have historically bee systematically deprived of SRH services or eglected. I more recet history, these groups are ofte ot prioritized withi atioal-level policies ad programs. Govermets must be held accoutable for allowig health iequalities to persist ad their cosequeces poorer SRH outcomes for vulerable, uderserved ad disadvataged groups. This Idex provides a sapshot of how coutries are doig overall to realize the sexual ad reproductive health ad rights of their citizes. However, this type of aggregate aalysis fails to capture a variety of health iequities that exist withi coutries. A cofluece of socioecoomic, social ad geographic factors affects a give idividual s sexual ad reproductive health. Data eeds to be collected at the atioal ad subatioal levels so that it ca be disaggregated to uderstad what is happeig amog various subgroups: urba ad rural, rich ad poor, youg ad old. There must be a commitmet to esurig uderserved, disadvataged ad historically eglected groups have access to sexual ad reproductive health iformatio, services ad supplies. This isert discusses several key sources of iequity that if addressed could vastly improve SRH: socioecoomic status, geography ad margializatio of certai populatios. I reality, each type of iequity idetified here is represeted across our four dimesios of sexual ad reproductive health ad rights (SRHR). I this sectio, the iequities discussed are oly explored i relatio to oe dimesio of SRHR. SOCIOECONOMIC STATUS Policies ad programs must esure that SRH iformatio, services ad supplies are accessible to ad meetig the eeds of the most socioecoomically disadvataged. Evidece cosistetly shows that poorer, less educated wome are less likely to be usig cotraceptives, eve whe they wat to avoid a pregacy. Amog wome i the poorest wealth quitile withi developig coutry households, approximately oe-third have a umet eed for family plaig. For example, Zimbabwe (Idex Score: 68.1/100) has a relatively high overall cotraceptive prevalece rate but there are disparities across wealth quitiles. Oly 52.4 percet of wome i the lowest wealth RIGHTS AND RESULTS I 51 I

55 quitile use a moder cotraceptive method compared to 63.6 percet of wome i the highest wealth quitile. * Wome i the lowest wealth quitile also rely more heavily o less effective, traditioal methods compared to wome i higher wealth quitiles. A UNFPA report lookig at 24 sub- Sahara Africa coutries demostrated that educatio is also associated with cotraceptive use: 42 percet of wome with a secodary school educatio were usig a cotraceptive method compared to 24 percet wome with a primary school educatio ad 10 percet of wome with o educatio. 1 *2010 Zimbabwe DHS. GEOGRAPHY Where you live i the world has a tremedous impact o your educatio, ecoomic opportuities, idividual agecy ad health. The same is true withi coutries. Rural populatios have cosistetly faced obstacles to accessig health services, icludig reproductive health iformatio, services ad supplies. Additioally, as the developig world becomes icreasigly urba, residets of urba slums are facig similar challeges to their rural couterparts. For example, physical barriers limit rural wome s ability to access quality materal health care; as a result, rural wome are less likely to deliver with a skilled birth attedat. I urba settigs, slum dwellers face similar challeges as public services, icludig health facilities, are rarely located close to slums. For example, i Keya (Idex Score: 62.6/100) the materal mortality rate i urba slums 706 materal deaths per 100,000 live births was almost double the atioal average of 488 materal deaths per 100,000 live births. 2 MARGINALIZED GROUPS Sexual ad reproductive health programs must meet the eeds of diversifyig populatios. As a result, policies ad programs must prioritize ad esure access to historically uderserved ad disadvataged groups, icludig ethic miorities, the urba poor ad margialized groups like sex workers. Though Vietam raks highly o our Idex (Idex Score: 77.2/100), the coutry faces disparities i materal health care. Accordig to oe study, rural wome i Vietam have made gais i skilled attedace at birth ad ateatal visits. However, these gais were greatest amog wealthier rural wome belogig to the primary ethic group, Kih/Hoa. 3 Poor wome belogig to a ethic miority remaied much more likely to deliver at home ad did ot have sigificat gais i ateatal visits. 4 Our Idex is a atioal summary measure, ad as such it iheretly fails to capture disparities withi ay give coutry. Data eeds to be collected at the atioal ad subatioal levels so that it ca be disaggregated to uderstad what is happeig amog various subgroups: urba ad rural, rich ad poor, youg ad old. There must be a commitmet to esurig uderserved, disadvataged ad historically eglected groups have access to SRH iformatio, services ad supplies. I 52 I A REPRODUCTIVE HEALTH INDEX

56 Edotes Mberu et al. Brigig Sexual ad Reproductive Health i Urba Cotexts to the Forefrot of the Developmet Ageda: The Case for Prioritizig the Urba Poor. Materal ad Child Health Joural, December 19, Målqvist, Mats et al. Materal health care utilizatio i Viet Nam: icreasig ethic iequity. Bulleti of the World Health Orgaizatio, 91: , doi: 4 Ibid. RIGHTS AND RESULTS I 53 I

57 I 54 I A REPRODUCTIVE HEALTH INDEX IN FOCUS: YOUTH

58 Curretly there are 1.8 billio youth betwee the ages of i the world ad 89 percet of them live i developig coutries. 1 That s 1.8 billio people who have their etire lives ahead of them to become doctors, start busiesses, ru for political office ad achieve life goals ad aspiratios. Oe of the ways to esure they ca achieve their goals is to guaratee they have cotrol over their sexual ad reproductive health. Ufortuately, stigma cotiues to impede ivestmets i, provisio of, ad access to sexual ad reproductive health services for youg people, eve though up to 59 percet of girls are sexually active by the age of As a result, youth ofte face greater barriers accessig ad utilizig sexual ad reproductive health services, which hampers their ability to pla for their futures. 3 Adolescets are adversely affected by some of the most pressig issues i global health, icludig early marriage, uiteded pregacy, usafe abortio ad HIV. However, whe girls stay i school they delay sexual iitiatio, marry later, have greater autoomy ad are less likely to become pregat as a adolescet. 4 Ivestmet i girls educatio ad icreasig acceptace of ad access to youth sexual ad reproductive health services will help decrease egative health outcomes ad esure youth everywhere are able to ejoy healthy sexual ad reproductive lives. UNINTENDED PREGNANCY AND EARLY MARRIAGE Without access to cotraceptio, youth ofte suffer from uiteded pregacies, whether i or out of marriage. Sixtee millio girls aged ad two millio girls uder age 15 give birth each year. These pregacies are ofte uiteded, uwated, coerced or mistimed. 5 More tha 14 millio girls worldwide are married before their 18 th birthday, puttig them at additioal risk for early pregacy. 6 Whe facig a lack of support or resources for a uiteded pregacy, a youg perso may either seek out abortio services that are ofte usafe or carry the pregacy to term ad face health risks associated with early pregacy (girls aged 15 to 19 are twice as likely to die from obstetric causes as older wome.) 7 I additio to health risks, early pregacies ad marriages ofte mea a youg girl is o loger erolled i school or workig o her ow, limitig her autoomy. UNSAFE ABORTION AND CHILDBIRTH Materal mortality remais the secod leadig cause of death amog wome aged Oe of the leadig cotributors to high materal mortality amog adolescets RIGHTS AND RESULTS I 55 I

59 is usafe abortio. Abortio is ot legal i most developig coutries, ad eve whe it is available, youth are ofte prohibited from accessig these services. Whe girls obtai usafe abortios, they are at risk for severe health cosequeces due to iadequate care, dirty istrumets ad lack of kowledge by those admiisterig the procedure. Almost 14 percet of all usafe abortios occur i wome uder age 20, a umber that is most likely uderreported due to the stigma attached to abortio. 9 Usafe abortio complicatios ca ot oly cause death but may also result i ifertility. I cultures where a woma s worth is depedet o childbearig, a ifertile youg woma may be shued or cast out of her house. HIV Youg girls are at icreased risk for materal morbidity whe givig birth eve with a desired pregacy, ad ifats bor to mothers uder 20 are more susceptible to low birth weight, ifat mortality ad stutig. 10 While ew HIV ifectios have falle by 38 percet sice 2001, percet of ew HIV ifectios are amog youg people aged Youg wome remai disproportioately affected by HIV ad are 50 percet more likely to acquire HIV tha youg me. 13 Access to testig ad treatmet is vital for youg wome so they ca live the healthiest life possible ad take steps to prevet mother-to-child trasmissio i curret or future pregacies. Oe of the protective factors agaist the issues discussed is access to educatio, especially girl s educatio. Whe girls stay i school, they delay sexual iitiatio, marry later, have greater autoomy ad are less likely to become pregat as a adolescet. 14 Ivestmet i girls educatio ad icreasig acceptace of, ad access to, youth sexual ad reproductive health services will help decrease egative health outcomes ad esure youth everywhere are able to ejoy healthy sexual ad reproductive lives. I 56 I A REPRODUCTIVE HEALTH INDEX

60 Edotes 1 Uited Natios Populatio Fud (UNFPA). The Power of 1.8 Billio: Adolescets, Youth ad the Trasformatio of the Future. New York: UNFPA, Iteratioal Ceter for Research o Wome. Uderstadig the Adolescet Family Plaig Base. Washigto, D.: ICRW, Guttmacher Istitute ad the Iteratioal Plaed Parethood Federatio. Demystifyig Data: A Guide to Usig Evidece to Improve Youg People s Sexual Health ad Rights. New York: Guttmacher Istitute ad IPPF, Overseas Developmet Istitute ad Save the Childre. Chartig the Future: Empowerig girls to prevet early pregacy. Lodo: ODI ad Save the Childre, Iteratioal Ceter for Research o Wome (ICRW). Uderstadig the Adolescet Family Plaig Base. Washigto, DC: ICRW, ICRW. More Power to Her: How Empowerig Girls Ca Help Ed Child Marriage. Washigto, DC: ICRW, Populatio Research Bureau. Family Plaig Saves Lives. Washigto, DC: PRB, UNFPA. The Power of 1.8 Billio: Adolescets, Youth ad the Trasformatio of the Future. New York: UNFPA, ICRW. Uderstadig the Adolescet Family Plaig Base. Washigto, DC: ICRW, Ibid. 11 Joit Uited Natios Programme o HIV/AIDS (UNAIDS), Fact Sheet ICRW. Uderstadig the Adolescet Family Plaig Base. Washigto, DC: ICRW, UNAIDS Programme Coordiatig Board. Thematic Segmet: HIV, adolescets, ad youth. pcb33/agedaitems/ _thematic-segmet-hiv-%20youth-adolescets%20.pdf. 14 Overseas Developmet Istitute (ODI) ad Save the Childre Chartig the Future: Empowerig girls to prevet early pregacy Lodo, UK: ODI ad Save the Childre. RIGHTS AND RESULTS I 57 I

61 I 58 I A REPRODUCTIVE HEALTH INDEX IN FOCUS: HUMANITARIAN SETTINGS

62 Coflict ad other humaitaria crises ca devastate basic public services, icludig the health system. I 2013, 81 millio people aroud the world were i eed of humaitaria assistace as a result of atural disasters, coflict or other emergecies; half of these idividuals were wome ad girls. 1 FRAGILE INDEX COUNTRIES INDEX SCORE Zimbabwe 68.1 Liberia 67.9 Kiribati 58.6 Sierra Leoe 58.0 Nepal 55.6 Haiti 55.5 Cogo 55.4 Solomo Islads 55.4 Togo 52.3 Burudi 51.8 Eritrea 51.8 Malawi 50.9 Comoros 47.2 Timor-Leste 46.7 Guiea-Bissau 44.1 Madagascar 42.1 Democratic Republic of Cogo 41.7 Côte d Ivoire 39.2 Mali 39.1 Chad 25.5 Of the 62 coutries that appear i our Idex, 20 coutries are cosidered fragile situatios by the World Bak. 2 The vast majority of these coutries fall squarely i the middle or lower half of the Idex. Too ofte, sexual ad reproductive health is treated as a afterthought durig crisis situatios ad humaitaria settigs. Evidece shows that durig emergecies, the eed for reproductive health iformatio ad services rises, but the ability to access critical reproductive health care services declies. People i humaitaria settigs cotiue to have sexual ad reproductive health eeds ad face icreased threats to their reproductive health. 3 Despite the existece of iteratioal stadards for reproductive health care i emergecy settigs, such as the Miimum Iitial Service Package (MISP) for Reproductive Health, these services are ofte eglected from the start of emergecies, ad fudig for these programs is ofte iadequate. Esurig urget ad effective resposes i humaitaria crises requires recogitio ad commitmet to the lifesavig ature of sexual ad reproductive health iformatio ad services. While each coutry s circumstaces are uique, it is critical to recogize the life-savig ad resiliece-buildig ature of sexual ad reproductive health iformatio, services ad supplies. Emergecy services, basic medical care, saitatio ad safe housig are irrefutably priority cocers that must be addressed. Esurig idividuals sexual ad reproductive health ad rights caot fall by the wayside, eve i a crisis. These services should be prioritized i order to: prevet uiteded pregacies, reduce materal morbidity ad mortality, deliver access to safe abortio where legal, prevet sexual violece ad reduce the trasmissio of HIV. RIGHTS AND RESULTS I 59 I

63 UNINTENDED PREGNANCY I humaitaria settigs, wome still have a eed to decide the timig of their pregacies exercisig this right will make them more resiliet. Despite this clear eed for cotraceptive services, crises-affected coutries have some of the highest rates of umet eed for family plaig. For example, the umet eed for family plaig has actually icreased i Chad over time from 17.4 percet of married wome i 1997 to 28.3 percet i MATERNAL HEALTH I additio to supportig resiliecy, cotraceptive access ca save wome ad girls lives by eablig them to prevet a uiteded pregacy i a high-risk situatio. Without access to skilled birth attedats, clea ad safe health facilities ad ecessary supplies, givig birth i a humaitaria settig poses tremedous risks. Not surprisigly, materal mortality ratios are high, with some coutries like Chad still approachig extremely high materal mortality ( 1,000 materal deaths per 100,000 live births). ACCESS TO SAFE ABORTION Humaitaria settigs ad related coflicts are ofte characterized by violece agaist wome. As a result, wome s eed for a rage of cotraceptive methods icludig emergecy cotraceptio ad safe abortio services caot be igored. Wome should be able to access safe abortio uder ay circumstace. However, may coutries cotiue to place strict limitatios o abortio. Of the 138 coutries aroud the world that place restrictios o access to abortio, 41 of these coutries allow exceptios i the case of rape, icludig Mali, Liberia, Togo ad Zimbabwe. 5 Victims of rape must be able to access safe abortio services; medical abortio presets a safe optio eve i humaitaria settigs. SEXUALLY TRANSMITTED INFECTIONS, INCLUDING HIV Disease trasmissio is a serious cocer, but sexual ad reproductive health (SRH) itervetios i humaitaria settigs eed to go beyod provisio of codoms. Recogizig that coditios are eve more difficult ad there are competig cocers i a crisis situatio, the sexual ad reproductive health ad rights (SRHR) eeds of idividuals cotiue to demad greater attetio. Idividuals eed access to a wide rage of SRH iformatio ad services, icludig cotraceptive access, safe delivery ad safe abortio. Ulike most developmet scearios, humaitaria crises ca happe uexpectedly ad are cotiuously chagig. Esurig urget ad effective resposes i these scearios requires recogitio ad commitmet to the life-savig ature of SRH iformatio ad services. SRHR eeds do ot stop i a crisis; rather, the risk of adverse outcomes is actually amplified. Sexual ad reproductive health must be cosidered a itegral piece of health care i humaitaria settigs ad prioritized accordigly. I 60 I A REPRODUCTIVE HEALTH INDEX

64 Edotes The World Bak. Harmoized List of Fragile Situatios FY K4Health. Reproductive Health I Humaitaria Settigs Toolkit. 4 UN Developmet Programme. 5 RIGHTS AND RESULTS I 61 I

65 I 62 I A REPRODUCTIVE HEALTH INDEX ANNEX 1 COUNTRY INDICATORS AND INDEX SCORES

66 RHI SCORE RANGE: = Highest = Mid-High = Middle = Low 0-20 = Lowest RANK Coutry % demad satisfied for cotraceptio % Iformed Choice Grouds o which abortio is permitted Status of Misoprostol o Essetial Medicie Lists % of live births for which woma have ateatal care coverage - at least four visits % of births atteded by skilled health persoel % wome with a STI or STI symptoms who sought advice or treatmet a health professioal % of wome with kowledge of 2 HIV prevetio methods - usig codoms ad limitig sexual itercourse to oe uifected parter % of wome receivig atiretroviral therapy amog wome eligible % of wome age who were NOT married before age 18 % of curretly married wome who participate i all surveyed household decisios 1 Ukraie No data No Data Viet Nam 94.8 No Data No Data No Data Armeia Swazilad No data Republic of Moldova Cabo Verde Kyrgyzsta Cambodia Guyaa Zimbabwe Hoduras Liberia Mogolia No Data No Data Ghaa Rwada Keya Zambia Tajikista No Data RHI SCORE GROUNDS ON WHICH ABORTION IS PERMITTED Without restrictio as to reaso IV 100 Socioecoomic grouds (also to save the woma s life ad health) III 90 To preserve metal health (also to save the woma s life) II - MH 60 To preserve physical health (also to save the woma s life) II 30 I case of rape or icest (also to save the woma s life) I R/I 20 To save the woma s life I SWL 10 Prohibited I 0 STATUS OF MISOPROSTOL FOR POSTABORTION CARE (PAC) Listed o EML with PAC idicatio specified 100 Listed o EML for o-pac uses (e.g. postpartum hemorrhage or other uses oly) or o idicatio specified 40 Not listed o EML 0 RIGHTS AND RESULTS I 63 I

67 RANK 19 Bolivia (Pluriatioal State of) Sri Laka No Data Sao Tome ad Pricipe No Data Kiribati 44.3 No Data No Data 78.8 No Data Vauatu No Data 59.5 No Data Sierra Leoe No data Nepal Haiti Lesotho Cogo Solomo Islads No Data Bei Bhuta 84.9 No Data No Data No Data Idia No Data Togo 29.0 No Data No Data No Data Ugada Eritrea 23.5 No Data Burudi Philippies No Data Malawi Coutry Uited Republic of Tazaia % demad satisfied for cotraceptio % Iformed Choice Grouds o which abortio is permitted Status of Misoprostol o Essetial Medicie Lists % of live births for which woma have ateatal care coverage - at least four visits % of births atteded by skilled health persoel % wome with a STI or STI symptoms who sought advice or treatmet a health professioal % of wome with kowledge of 2 HIV prevetio methods - usig codoms ad limitig sexual itercourse to oe uifected parter % of wome receivig atiretroviral therapy amog wome eligible Idoesia Morocco % of wome age who were NOT married before age 18 % of curretly married wome who participate i all surveyed household decisios RHI SCORE I 64 I A REPRODUCTIVE HEALTH INDEX

68 RANK 42 Lao People's Democratic Republic 71.4 No Data 0 No Data No Data Cameroo Nigeria Egypt No Data Comoros No data Timor-Leste No Data Burkia Faso Seegal Guiea-Bissau 70.3 No Data No Data No Data Mozambique No Data Madagascar Coutry Democratic Republic of the Cogo % demad satisfied for cotraceptio % Iformed Choice Grouds o which abortio is permitted Status of Misoprostol o Essetial Medicie Lists % of live births for which woma have ateatal care coverage - at least four visits % of births atteded by skilled health persoel % wome with a STI or STI symptoms who sought advice or treatmet a health professioal % of wome with kowledge of 2 HIV prevetio methods - usig codoms ad limitig sexual itercourse to oe uifected parter % of wome receivig atiretroviral therapy amog wome eligible Guiea Côte d'ivoire Ethiopia Mali Pakista Bagladesh Mauritaia 26.8 No Data No Data No Data Niger Chad 14.5 No Data No Data 25.5 % of wome age who were NOT married before age 18 % of curretly married wome who participate i all surveyed household decisios RHI SCORE RIGHTS AND RESULTS I 65 I

69 I 66 I A REPRODUCTIVE HEALTH INDEX ANNEX 2 REPRODUCTIVE HEALTH INDEX 2015

70 CONCEPTUAL FRAMEWORK, DATA SOURCES AND METHODOLOGY GEOGRAPHIC COVERAGE The study raks 62 low-icome ad lowermiddle-icome coutries * from highest to lowest attaimet of sexual ad reproductive health ad rights (SRHR). The Idex is comprised of ie idicators capturig the drivers/determiats of wome s reproductive health ad rights status, as well as two rights-based idicators idicative of a eablig eviromet. Data collected prior to 2004 has bee excluded from the Idex. Twety coutries with four or more missig data poits/ idicators were ot icluded i this study. CONCEPTUAL FRAMEWORK The study s coceptual framework is based o the 1994 Programme of Actio (POA) of the Iteratioal Coferece o Populatio ad Developmet (ICPD). The POA provides a comprehesive ad iteratioally recogized coceptualizatio of reproductive health ad rights. Stemmig from the POA, this study defies SRHR accordig to the followig four dimesios: Prevetig uiteded pregacy; Icreasig access to safe abortio ad post-abortio care; Helpig wome safely through pregacy, childbirth ad the postpartum period; ad Prevetig ad treatig sexually trasmitted ifectios, icludig HIV/AIDS. Rather tha measurig the health outcomes correspodig to the four dimesios oted above, this Idex captures the factors drivig the attaimet of SRHR. Determiats iclude access to high-quality, volutary ad affordable health services ad supplies; access to high-quality iformatio; ad o-restrictive/o-coercive legal ad policy frameworks. As a result, this Idex ecapsulates the key dimesios of reproductive rights icludig the right to reproductive self-determiatio; the right to sexual ad reproductive health services, iformatio ad educatio; ad the right to equality ad o-discrimiatio. Importatly, this study also cosiders determiats of SRHR beyod the health system, termed the eablig eviromet, which serves as the fifth dimesio of the Idex. CONSTRUCTION OF INDEX Buildig o the coceptual framework, idicators were chose based o: 1) their applicability to the drivers of the four dimesios of SRHR defied above ad eablig eviromet; 2) their represetativeess of at least oe of three dimesios of reproductive rights; ad 3) the availability of comparable ad high-quality atioal data. Reproductive health is the state of complete physical, metal ad social well-beig ad ot merely the absece of disease or ifirmity, i all matters relatig to the reproductive health system ad to its fuctios ad processes. Reproductive health therefore implies that all people are able to have a satisfyig ad safe sex life ad that they have the capability to reproduce ad freedom to decide if, whe ad how ofte to do so. Implicit i this last coditio are the right of me ad wome to be iformed ad to have access to safe, effective, affordable ad acceptable methods of family plaig of their choice, as well as other methods of their choice for regulatio of fertility which are ot agaist the law, ad the right of access to appropriate health-care services that will eable wome to go safely through pregacy ad childbirth ad provide couples with the best chace of havig a healthy ifat. Uited Natios Programme of Actio of the Iteratioal Coferece o Populatio ad Developmet. A/CONF.171/13/Rev.1 * Coutry classificatios are based o those established by the World Bak. ** These coutries are: Afghaista, Cetral Africa Republic, Democratic People s Republic of Korea, Djibouti, El Salvador, Gambia, Georgia, Guatemala, Microesia (Federated States of), Myamar, Nicaragua, Papua New Guiea, Paraguay, Samoa, Somalia, South Suda, Suda, Syria Arab Republic, Uzbekista ad Yeme. RIGHTS AND RESULTS I 67 I

71 The Idex is composed of the followig 11 idicators: DIMENSION PREVENTING UNINTENDED PREGNANCY INDICATOR 1. Percet demad satisfied for cotraceptio amog curretly married wome* 2. Iformed choice INCREASING ACCESS TO SAFE ABORTION AND POST-ABORTION CARE 3. Grouds o which abortio is permitted (legal status) 4. Status of misoprostol for postabortio care (registered o Essetial Medicie Lists) HELPING WOMEN SAFELY THROUGH PREGNANCY, CHILDBIRTH AND POSTPARTUM 5. The percetage of live births for which woma have ateatal care coverage (at least four visits) 6. Percetage of births atteded by skilled health persoel PREVENTING AND TREATING STIs, INCLUDING HIV/AIDS 7. Percetage of wome with a STI or STI symptoms who sought advice or treatmet from a cliic, hospital, private doctor, or other health professioal 8. Percetage of wome age with kowledge of HIV prevetio methods (usig codoms ad limitig sexual itercourse to oe uifected parter) 9. Percetage of wome receivig atretroviral therapy amog wome eligible ENABLING ENVIRONMENT 10. Percetage of wome age years old who were ot married or i uio before they were Percetage of curretly married wome age who participate i all surveyed household decisios (either by themselves or joitly with their husbad) * The idicator percet demad satisfied amog curretly married wome was computed as follows: 100*(cotraceptive prevalece married wome/(cotraceptive prevalece married wome + umet eed for FP married wome)). The idicator iformed choice was calculated as the average of three measures: percet moder users iformed of side effects, percet who were iformed about what to do if side effects occur ad percet who were iformed of other methods available. Because a higher Idex score represets a more positive status for wome, this idicator was calculated by subtractig the prevalece of child marriage from 100 to reflect the percetage of wome who were ot married or i uio before age 18. I 68 I A REPRODUCTIVE HEALTH INDEX

72 Nie quatitative idicators composig the Idex are scored o a 100-poit scale of 0 to 100. Of the two ordial/ categorical idicators, scores were assiged as follows: DIMENSION STATUS OF MISOPROSTOL FOR POST-ABORTION CARE (PAC) GROUNDS ON WHICH ABORTION IS PERMITTED INDICATOR Listed o EML with PAC idicatio specified 100 Listed o EML for o-pac uses (e.g. postpartum hemorrhage or other uses oly) or o idicatio specified Not listed o EML 0 Without restrictio as to reaso IV 100 Socioecoomic grouds (also to save woma s life ad health) III 90 To preserve metal health (also to save the woma s life) II - MH 60 To preserve physical health (also to save the woma s life) II 30 I case of rape or icest (also to save the woma s life) I R/I To save the woma s life I SWL 10 Prohibited I 0 For the costructio of the Idex, equal weight is give to all 11 idicators. The fial composite score, which is the overall coutry score, is derived by dividig the sum of the idicators by 11. For 24 coutries with three or less missig data poits, the fial composite score was geerated by adjustig the deomiator to reflect the total umber of data poits available. As modeled by the Idex, the strogest possible state of SRHR i a coutry would be a score of 100. The results of our study show the calculated composite Idex scores for the 62 coutries rage from 25.5 to Based o their Idex scores, coutries are raked ad classified. For compariso to oe aother, coutries are raked from highest to lowest sexual ad reproductive health ad rights. To compare a coutry s calculated score to the strogest possible state of SRHR, coutries are classified as follows: the possible idex rage of 0 to 100 is divided ito quitiles ad coutries are the grouped based o which quitile their calculated Idex score falls: HIGH INDEX SCORES 80 TO COUNTRY MID-HIGH INDEX SCORES 60 TO COUNTRIES MIDDLE INDEX SCORES 40 TO COUNTRIES LOW INDEX SCORES 20 TO 39 9 COUNTRIES LOWEST INDEX SCORES 0 TO 19 0 COUNTRIES RIGHTS AND RESULTS I 69 I

73 DATA SOURCES Data were collected ad updated util March 1, INDICATOR: 1. Percet demad satisfied amog curretly married wome 2. Iformed choice SOURCE(S): ICF Iteratioal Demographic ad Health Surveys (various). Calverto, MD: ICF Iteratioal. Uited Natios Populatio Divisio World Cotraceptive Use New York: Uited Natios Populatio Divisio. ICF Iteratioal Demographic ad Health Surveys (various). Calverto, MD: ICF Iteratioal. 3. Grouds o which abortio is permitted (legal status) Ceter for Reproductive Rights, The World s Abortio Laws Map (2014). 4. Status of misoprostol for post-abortio care (registered o Essetial Medicie Lists) World Health Orgaizatio. Natioal Medicies List/Formulary/Stadard Treatmet Guidelies. 5. Ateatal care coverage (at least four visits) World Health Orgaizatio (WHO) Global Health Observatory Data Repository. 6. Births atteded by skilled health persoel World Health Orgaizatio (WHO) Global Health Observatory Data Repository. 7. Percet wome seekig advice or treatmet for STI or potetial STI symptoms from a cliic, hospital, private doctor, or other health professioal ICF Iteratioal Demographic ad Health Surveys (various). Calverto, MD: ICF Iteratioal. 8. Percet wome with kowledge of HIV prevetio methods(usig codoms ad limitig sexual itercourse to oe uifected parter) 9. Atiretroviral coverage amog wome eligible 10. Percet curretly married wome age who participate i all decisios (either by themselves or joitly with their husbad) 11. Percet wome years old who were first married or i uio before they were 18 ICF Iteratioal Demographic ad Health Surveys (various). Calverto, MD: ICF Iteratioal. Uited Natios Childre s Fud (UNICEF) Multiple Idicator Cluster Surveys (various). New York: UNICEF. World Health Orgaizatio. Access to atiretroviral drug by sex, (made available by the Global Geder Statistics Programme, implemeted by the Uited Natios Statistics Divisio: ICF Iteratioal Demographic ad Health Surveys (various). Calverto, MD: ICF Iteratioal. Uited Natios Childre s Fud (UNICEF) Global Database. New York: UNICEF. Natioal surveys were also used to supplemet the above sources. I 70 I A REPRODUCTIVE HEALTH INDEX

74 DATA LIMITATIONS AND QUALITY A umber of issues related to data quality ad availability surfaced throughout the course of the study. Natioal statistics o wome s health are ofte of poor quality, lackig or outdated, especially where vital registratio systems are ot well developed. Defiitios vary from oe coutry to aother ad ca ofte vary withi coutries. The atioal-level statistics used i this aalysis, while they elucidate the differetials betwee poor ad rich coutries, mask differetials i reproductive health withi coutries. For example, data are ofte iadequately differetiated by geder, age group, place of residece or socioecoomic status. Also, statistics o coverage of health services do ot reflect the quality of available care. Much of the data collected are from Demographic ad Health Surveys (DHS) or similar sources that are oly updated every three to four years or i some cases, loger. Cosequetly, a coutry may be makig sigificat improvemets i SRHR that wo t be reflected i their Idex score for several years. No matter how a idex is costructed ad how may idicators it has, it will always etail a large degree of geeralizatio ad estimatio. This is true firstly because idicator selectio is largely restricted by data availability ad quality. Furthermore, while idicators are valuable tools for a broad aalysis, they caot measure the full scope of ay oe issue. For example, misoprostol beig listed o a coutry s EML ca be idicative of the road toward icreasig availability of the drug. It does ot tell us what is actually beig provided o the groud. The same is true aroud policies regardig abortio abortio may be legal uder certai circumstaces but that aloe does ot tell us whether wome kow that it s legal or whether or ot doctors are willig to provide the service to wome who wat it ad are etitled to it uder the law. Accordigly, a fuller picture of wome s SRHR status requires aalysis of additioal iformatio, ofte o smaller scales (e.g.,. subatioal level). RIGHTS AND RESULTS I 71 I

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