Others have outlined the many benefits of investment in family planning, including acceleration of progress towards achieving the Millennium Development Goals. We explain how measures to respect, protect, and fulfil human rights1 enable people to use contraceptive information and services and help achieve the full benefits of such investments.
Many people think of human rights in terms of violations. This aspect is important, and the history of family planning policies and programmes—particularly some undertaken for population control— includes instances of people being coerced to accept contraceptive implants or intrauterine devices and being subjected to forced abortion or sterilisation.2–9 Human rights mechanisms, such as treaty monitoring bodies, regional human rights tribunals, and national courts, enable individuals and communities to seek redress for such violations.6, 7 Human rights law can also be used to prevent violations occurring in the first place. For example, consideration of human rights standards can ensure that health services do not discriminate against particular groups such as people younger than 18 years, ethnic minorities, or people with HIV infection, and can also require improvements in the quality of services. When human rights are integrated into policy-making processes, they can help to ensure that health facilities and services are non-discriminatory and of good quality from the outset. The application of human rights law and standards to programme design and monitoring, and use of human rights mechanisms to hold governments accountable, are essential devices to ensure health for all.
Internationally agreed human rights that are particularly relevant to contraceptive information and services include the rights to: non-discrimination, information and education, the highest attainable standard of health, privacy, and life.10–12 These rights are inextricably linked. For example, the right to the highest attainable standard of health, which includes access to health services and health-related information, cannot be fulfilled without promotion and protection of the rights to education and information because people must know about services to use them. In this report we give special attention to the right to contraceptive information and services, which is grounded in these internationally recognised human rights,13, 14 and we suggest that the promotion and protection of these rights should be part of a multidimensional strategy to satisfy the unmet need for family planning.
Over the past four decades, international human rights law has established and expanded standards for sexual and reproductive health, including family planning. For example, states have affirmed the right to the highest attainable standard of health,10 authoritatively interpreted to encompass “sexual and reproductive health services, including access to family planning”.15 They have also agreed to “eliminate discrimination against women in the fleld of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning”.11
These agreements are legally binding for all the countries that have ratified the relevant covenants and conventions, such as the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of the Child (CRC), and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). All states in the world have ratified at least one of the core international human rights treaties and most have ratified many more.16 Many have translated these standards into their national laws and regulations, and many national constitutions guarantee rights such as the right to non-discrimination. These standards place legal obligations on governments to make high quality contraceptive information and services accessible for everyone, and to enable people to demand access to such services.
Human rights treaties are supported and amplified by intergovernmental consensus documents such as the Programme of Action of the International Conference on Population and Development.17 Such agreements can be used by various groups to hold accountable the governments that are party to them, and they also guide the policies and programmes of UN agencies, donor governments, and nongovernmental organisations.
Because this series focuses on family planning, defined as contraceptive information and services, we do not discuss access to other essential sexual and reproductive health services such as prevention, diagnosis, and treatment of sexually transmitted infections, and provision of safe abortion, although access to safe abortion is also central to women’s ability to regulate their fertility. International human rights law requires that governments provide a comprehensive legal and policy framework to ensure that abortion services allowable by law are safe and accessible in practice.18–20 This obligation requires that health providers be trained and equipped, and that other measures be taken to protect women’s health. Other issues crucial to the health and human rights of women are outside the scope of this report, such as early and forced marriage and female genital mutilation, both of which breach international human rights law.12, 21–23
Whose Unmet Need?
The human rights principle of non-discrimination leads us to examine who is included in prevailing definitions of unmet need by policy makers, programme managers, service providers, and demographers. The sources used to estimate unmet need generally include only married or cohabiting women of reproductive age who do not want to become pregnant, but who are not currently using a modern method of contraception. However, as data have become available from some countries for sexually active unmarried women, the most recent unmet need estimates include unmarried women. About 215 million women in developing countries are estimated to have an unmet need for family planning.24 Still left out of the estimate are women who are using a modern method that is unsatisfactory to them and who, without the necessary programme support, are at risk of unwanted pregnancy or of stopping contraceptive use or both. Boys and men are not explicitly addressed in estimates of unmet need because the woman who reports contraceptive use is asked to include use by her husband or partner.
About half all sexually active adolescent women (aged 15–19 years) in sub-Saharan Africa and Latin America and the Caribbean who want to prevent pregnancy are unmarried.25 Of those, only 41% in sub-Saharan Africa and 50% in Latin America and the Caribbean are using a modern method of contraception. No equivalent data for sexually active adolescent men are available. Yet, there are 1.4 billion adolescents aged 10–19 years, many of whom are, or soon will be, sexually active. About 90% of them live in low-income and middle-income countries, have limited access to schooling and health services, and are likely to engage in sexual activity before or outside, as well as within, marriage.
The decisions of these young people about beginning sexual activity, marriage, sexual expression, and use (or not) of contraception will have a great effect on their lives and determine a major portion of future population growth. Whether married or not, they have particular needs in family planning because they are more likely to have unprotected and non-consensual sex, and commonly lack the information and services needed to protect themselves.26 Nor are these young people drawn to services that are designed to meet adults’ needs. Many young people can be interested in contraception to prevent unwanted pregnancy and to protect against sexually transmitted infections, but conventional messages about planning their families are irrelevant. Addressing their needs requires trained and supportive staff, privacy and confidentiality, emphasis on both contraception and disease prevention, and comprehensive sexuality education which is grounded in human rights, including gender equality and non-discrimination, sexual attitudes, and behaviour.27–30
The many women who are using a method that they do not like are not currently considered to have an unmet need. In some countries, more than four women in ten discontinue their contraceptive method within the first year of use.31 Yet these women, before they discontinue, are not included in the estimates of unmet need, which is indicative of the long-standing failure of many programmes to recognise the importance of provision of suficient information about side-effects, and support for women to tolerate them or switch methods.
In all regions, entire categories of women have little or no access to contraceptive services; these groups include refugees and internally displaced women, those in stigmatised occupations such as sex work, those who are otherwise stigmatised, such as rape victims, women with disabilities, HIV infection, or AIDS, and those from religious or ethnic minorities.32–35 The human rights principle of non-discrimination requires that contraceptive information and services are available and accessible to all these groups. Special outreach, training, and other investments that are needed, will affect cost estimates of both global and national resources required to address the unmet need. In many countries, meeting these unmet needs will also require changes in laws, policies, strategies, and programmes, consistent with national and international human rights standards.
Use of Human Rights to Overcome Barriers to Access
The right to the highest attainable standard of health requires that everyone can access health information and services without restrictions, including specific services related to family planning15 that are both affordable and delivered in a timely fashion.33 Nonetheless, many barriers impede women’s access to contraception, including: conditions that do not allow them to make free and informed decisions (such as lack of intelligible information or counselling); lack of confidentiality; the requirement for authorisation by spouse, parent, or hospital authorities; high fees for services; distance from health facilities and the absence of affordable public transport; lack of choice of a wide range of contraceptive methods;36–40 and inadequate training, insufficient numbers, and poor supervision of health-care providers.17, 41
Laws that restrict access to services for particular population groups, or that ban the display of materials about, or sale of contraceptives, have been identified as serious barriers to women’s access to family planning services.40–44 Each of these barriers could be the focus of a report, but we describe below four examples where human rights standards have been used to remove barriers, thus contributing to reduction of unmet need.
Inadequate Supplies of Safe and Effective Commodities
Reports from the past 3 years show that, in some African countries, stock-outs of contraceptives are a chronic problem.45–47 In Kenya, for instance, 24% of women who do not want another child within the next 2 years are not using contraception because many methods, particularly implants and injectables, are not available.45 Such shortages are likely to contribute to maternal morbidity and mortality.45 In some instances, substandard contraceptives are available at low prices, but pose a serious threat to people’s lives and health.47 The human rights and public health obligations of governments require them to establish strict quality controls for manufacture and import of contraceptives, and effective surveillance of other sources such as the internet.
Human rights standards require that a wide range of approved contraceptive supplies be continuously available.11, 15, 36–39 Approved contraceptives are those, at a minimum, that are on the WHO Model List of Essential Medicines48 and its companion Essential Medicines for Reproductive Health.49 These lists include emergency contraception, a method that is often not available even when other methods are, and a range of contraceptives including condoms and other barrier methods, hormonal contraceptives (oral, injectable, implants, rings), intrauterine devices, and contraceptive sterilisation. An example of how human rights standards have been used is a decision by the Colombian Council of state, which ruled that access to emergency contraception is in accordance with the right to life as established in the Colombian Constitution, thus rejecting efforts by some groups to ban such contraceptives.44 Another problem is that the ability of states to ensure continuous supplies has been, and in many cases remains, dependent on donor funding, which has been reduced over the past decade, and on free supplies from international agencies, which can be erratic.45–46
Poor Quality Services
In the early 1990s, poor quality of care in contraceptive services was identified as a major problem, and a user-centred quality of care framework was designed that is implicitly grounded in human rights.50 Its elements are: choice among contraceptive methods; accurate information about the effectiveness, risks, and benefits of different methods; technical competence of providers; provider–user relationships based on respect for informed choice, privacy, and confidentiality; follow-up; and the appropriate constellation of services.50 The framework has been variously adapted to include additional elements such as cost, proximity of services, and consideration of gender relations. Studies in Bangladesh, the Philippines, Senegal, and Tanzania have shown that improvement of care quality according to these standards increases women’s contraceptive use; where women felt they were receiving good care, rates of contraceptive use were higher than in regions with lower quality provision of health care.51–54 In addition to the public health imperative, the right to the highest attainable standard of health obligates governments to ensure that health facilities, goods, and services, including contraceptive services, are of good quality.15 The framework provides guidance for this requirement and experience shows that it helps address unmet need by improving women’s satisfaction with and effective use of contraceptives and can increase the numbers of women and young people accessing services.
An apparently increasing number of health-care providers refuse to provide various sexual and reproductive health services including contraception on grounds of conscience, because they disagree, for personal or religious reasons, with the use of contraception. Human rights law is clear: providers’ exercise of their rights to freedom of thought, conscience, and religion must not jeopardise their patients’ health.33, 55 The European Court of Human Rights elaborated this standard in a case in which two pharmacists in France were found liable for refusing to provide doctorprescribed contraceptives to several women on religious grounds.55 The court explained that as long as the sale of contraceptives is legal and occurs by medical prescription only in pharmacies, pharmacists “cannot impose their religious beliefs on others as a justification for their refusal to sell such products, … [They] can manifest those beliefs in many ways outside the professional sphere”.55 The pharmacists were subsequently also found guilty of violating France’s Consumer Code, which prohibits refusal to sell a product or provide a service to a customer for no legitimate reason.55, 56 These decisions are consistent with the Ethical Guidelines of the International Federation of Gynecology and Obstetrics.57 Individuals who object on grounds of conscience to providing contraceptives must refer patients to willing providers, and provide services where they have a monopoly and in emergency situations.
Lack of Community Engagement
Participation in the decision-making process by the people who are affected is a core human rights principle. In family planning, if communities are not engaged in processes of contraceptive introduction, the result is likely to be less effective.58 In recognition of this, WHO has outlined a participatory approach to contraceptive introduction explicitly grounded in human rights, which has been effectively used in nearly 20 countries.58