Leading to ICPD30 No 4: Extracts from UNECE Regional Report on ICPD PoA: (b) Families, sexual and reproductive health over the life course

III        Key findings - Paras 17- 26

B         Families, sexual and reproductive health over the life course

The 2013 Chair’s summary called on Member States to “guarantee universal access to sexual and reproductive health (SRH) care” including, among other measures,  strengthening comprehensive sexuality education (CSE) programmes by training professionals; removing barriers to access contraceptive methods; eliminating preventable maternal mortality and morbidity; and ensuring the prevention of HIV and other sexually transmitted infections (STIs). 

As stated in the report “sexual and reproductive health and reproductive rights are central to sustainable development, critical to maternal, newborn, child and adolescent health, and fundamental for gender equality and women’s empowerment,” as well as being an essential part of universal health coverage (UHC). The report notes, however, that laws and regulations guaranteeing full and equal access to the four key dimensions of SRH (maternity care, contraception and family planning, CSE and HIV and human papillomavirus (HPV) only exist in 3 out of 41 countries with data available (the Kingdom  of the Netherlands, Norway and Sweden). While adolescent SRH is increasingly recognized as important, only 25 out of 39 countries reported that they had a national strategy or policy on adolescent health in 2022.

Recognizing maternal mortality as a “key indicator of women’s health and a measure of a health system’s efforts to promote SRH” and neonatal survival as reflecting the extent to which women and infants have been provided with access to quality SRH care before and during pregnancy, delivery, and the post-partum period, the following should be noted. There was a decline in maternal mortality in the region from 22 to 12 deaths per 100,000 live births between 2000 and 2020. Between 2015 and 2020 there has been an increase in the maternal mortality ratio in 18 of the 52 countries with data and the lifetime risk of maternal death is more than three times higher in countries in Central Asia (1 in 1,200)and Northern America (1 in 2,900) than in Western Europe (1 in 9,800). Since 2000 there has been a decrease in neonatal mortality  in all countries in the region from 8.4 in 2000 to 3.7 live births in 2021. Nevertheless it remains high in Central Asia and the South Caucasus region with gaps remaining among the most disadvantaged despite widespread access to antenatal care and skilled attendance at birth in most countries.

Between 2000 and 2020 there has been a fall in adolescent birth rates (ABR) from 20.3 to 12.6 births per 1,000 women aged 15 to 19 years. In Andorra, Denmark, Liechtenstein, Norway, San Marino and Switzerland (all high-income countries), the ABR is below two births per 1,000 women in this age group, compared with Central Asia at 24.9 in 2020 and in some Eastern European countries where the rates are three or four times the average for the region. In addition, ABR among Roma adolescents in Montenegro and Serbia is 10 times higher than among the same age group in the general population, and five times higher in North Macedonia. While early marriage is not common, in some countries prevalence remains high – in Albania, Georgia, Kyrgyzstan, the Republic of Moldova and Türkiye more than 1 in 10 women aged 20-24 were married before the age of 18, usually only having primary, as opposed to secondary, education. 

There has been little change since 2000 in contraceptive prevalence (any method) among women, married or in a union aged 15-49 with a slight increase in 2023 from 69.6 to 70.6 percent. Variations exist between countries eg, in Norway 85 percent of women in this cohort are using contraception as opposed to only 27 percent of women in the same cohort in Montenegro. One in three women in 15 countries in Central Asia, the Balkans and South Caucasus do not use any form of contraception, while one in six women in the region have an unmet need for modern methods of family planning, despite numbers generally decreasing in all countries. Few countries provide hormonal contraceptives over the counter with most family planning services being provided by specialist doctors. 

Between 2000 and 2019 induced abortion decreased from 393 to 189 per 1,000 live births, with significant reductions in Belarus, Romania, the Russian Federation and Ukraine from more than 1000 in 2000 to 350 or fewer in 2019. Some countries in Western Europe, however, have seen more abortions than live births among teenagers and younger women, with high teenage abortion rates in Northern European countries. This shows a need to educate young people about sexual health, including interventions to prevent unintended pregnancies. 

Twenty-eight countries reported in 2022 adopting policies requiring mandatory CSE as a part of the regular education curriculum or policy, as opposed to 19 in 2019. No legal frameworks supporting mandatory CSE in schools exist in Georgia, Azerbaijan, Kazakhstan or Romania, although non-compulsory pilots or programmes have been implemented in the latter three countries. Barriers to youth and adolescents accessing CSE include: limited curriculum content; insufficient teacher training; and a “persistent lack of confidence among teachers to deliver sexuality education”.

The latest HIV infection rates are alarming for some parts of the region – 160,000 people were newly infected with HIV in Eastern Europe and Central Asia (EECA) in 2022, showing a 49 percent increase since 2010, which was the largest increase in any region in the world during this period. AIDS-related deaths in EECA in 2022 were 46 percent higher than in 2010, despite expanded HIV treatment coverage, new prevention methods and measures to control opportunistic infections, and taking into account that fewer than half of those living with HIV receive antiretroviral therapy (ART). This increase is driven by a lack of HIV prevention services for marginalized and key populations and barriers such as punitive laws, social stigma and discrimination. While most countries in the region have national testing guidance in place, some policies are more than five years old and others lack content on key populations, or recommendations on testing frequency or specific methods for testing.

Worldwide cervical cancer was the leading cause of cancer and cancer deaths in women in 2020, and second most common cause of cancer-related deaths among women of reproductive age in EECA. Women living in high-income countries are more likely to be tested for cervical cancer and vaccinated for HPV, the greatest cause of cervical cancer. “Testing for and treatment of cervical cancer is free in 22 countries in the EU, as well as in Albania, Azerbaijan, Belarus, Serbia, Türkiye, Uzbekistan, and in Georgia and the Republic of Moldova. All EU/European Economic Area (EEA) countries have introduced HPV vaccination in their national programmes, and many have recently moved or are planning to move from a girls-only HPV vaccination strategy to a universal or gender-neutral vaccination strategy.” Inequities in access to the vaccine have been reduced between high- and middle-income countries and there has been a rapid increase in coverage in Albania, Estonia, Kyrgyzstan, Montenegro and Serbia.

It can be seen that progress has been mixed in securing sexual and reproductive health and reproductive rights across the region. Trends that require consideration include the need to change unfavourable societal environments; investing in programmes that fight gender inequality and harmful gender norms; empower women and girls to control their own sexual lives; access sexual and reproductive health care; and access respectful maternity care. Efforts should be strengthened for promoting SRH education and information; quality service delivery; and accessibility especially by those marginalized by societies.