Stephen Leahy | Brooklin, Canada
While world attention has focused on the HIV/Aids pandemic, public health experts say that United States political interference and declining financial support for family planning, abortion and prevention of other sexually transmitted infections has contributed to shockingly high death and disability rates in developing countries.
Approximately 500 000 women die each year of causes related to pregnancy, abortion and childbirth, 99% of them in developing countries, according to the World Health Organisation.
"These deaths would not be tolerated in other circumstances," says Dorothy Shaw, senior associate dean of the faculty of medicine at the University of British Columbia in Canada.
Countries are failing in their responsibilities and promises to fund sexual and reproductive health programmes, including supporting universal access to contraception, Shaw says. Contraception alone would dramatically reduce abortion rates, she says.
"More than 68 000 women die every year from back-alley or self-induced abortions," notes Janie Benson, vice-president of research and evaluation at Ipas, an NGO focused on increasing women's ability to exercise their sexual and reproductive rights and preventing unsafe abortions worldwide.
Many of the 20-million women who have unsafe abortions each year suffer from medical complications -- some for the rest of their lives, Benson says. "This is a preventable pandemic," she emphasises.
Legal abortions are extremely safe. And when abortion is made legal, it does not increase the number of abortions, she says, citing the South African experience as an example.
However, by making abortion legal, South Africa is no longer eligible for US Agency for International Development funding for sexual and reproductive health programmes, including some HIV/Aids programmes.
"We need governments to decide that women's lives are worth saving," Benson says.
Changes in US policy could make a substantial contribution to improving the sexual and reproductive lives of people worldwide, according to a series of six reports coordinated by the World Health Organisation and being published in the British medical journal Lancet this week.
Officially termed the Mexico City Policy, the Bush administration mandates that no US family planning assistance can be provided to foreign NGOs that use funding from any other source to perform, recommend or refer women for abortions.
The destructiveness of US policy is hard to understate, says Steven Sinding, former director general of the International Planned Parenthood Federation (IPPF).
The IPPF lost $15-million in funding because of this policy, known as the "gag rule" because it stifles free speech and public debate on abortion-related issues. "Three of the five family planning facilities supported by IPPF in Kenya were forced to close as a result," Sinding says.
The direct consequences of those closures were "a dramatic rise in unsafe abortions and substantial increase in unwanted pregnancies", he says.
"The US stands embarrassingly alone on this," agrees Stan Bernstein, senior policy adviser at the United Nations Millennium Project. "No other country supports denying access to sexual and reproductive health services over issues around abortion."
But because it is the world's wealthiest nation and donor, US policy has a major impact on the delivery of those services.
What is often forgotten in debates over policy and ideology is the fact that unwanted births and the subsequent health consequences are a major impediment to development. Low-income countries cannot keep pace with the present health needs of their young, and cannot improve without family planning, Bernstein says.
Between 1960 and 2000, the percentage of women using modern contraception globally increased from less than 10% to 60%, and the average number of births per woman fell from six to about three.
However, in half of the low- and lower-middle income countries, fertility, population growth and unmet family planning needs remain high while contraceptive use continues to be low. As a result, more than 120-million couples have an unmet need for modern contraception and an estimated 80-million women have unintended or unwanted pregnancies, with 45-million ending in abortion annually, the Lancet sexual and reproductive health series reported.
Pregnancy-related complications kill more than half a million women every year, and leave approximately 210-million women with disabilities.
In Africa, less than 10%of the population has access to contraceptives, says Bernstein. "Only the wealthy in Africa have the family size they want."
As for the White House's preferential strategy of promoting abstinence, most women have no control over their lives and cannot refuse to have sex, says Shaw. "Fifty percent of sexual assaults are on girls under the age of 15. That is the reality in many low-income countries," she says.
Family planning is a powerful tool for boosting development, but funding has dropped by 30% in recent years and is "desperately underfunded", says Sinding.
Current funding levels are less than half what the 179 countries committed to at the 1994 Cairo conference on population and development. As a result there has been no progress in 20 years, he says. "It's still 500 000 women dying every year, just as it was in 1994."
Between 1995 and 2003, donor support for family planning commodities and service delivery fell from $560-million to $460-million.
Family-planning programmes in Africa alone are projected to cost more than $270-million in 2006 and nearly $500-million in 2015. And the available funding for 2006 will be at least $70-million less than needed.
"Without major increases in funding there is no hope of improvement," says Sinding.