Doc. 9901

11 September 2003

Impact of the “Mexico City Policy” on the free choice of contraception in Europe

Report
Committee on Equal Opportunities for Women and Men

Rapporteuse: Mrs Zwerver (The Netherlands, Socialist Group)

Summary

The World Health Organisation (WHO) estimates that, every year, over 500.000 women die worldwide as a result of pregnancy related causes; seven million more become ill or disabled. In addition, some 40 million abortions occur each year, often under unsafe conditions – claiming some 70.000 extra female lives. In the developing world, pregnancy and childbirth remain the greatest single threat to a woman’s health in her reproductive years. Contrary to popular belief, Europe is also concerned by this blight.

Several international organisations and NGOs are working hard to realise the Cairo programme of action (adopted in 1994) and the Ottawa Statement of Commitment (adopted in 1999), which aim to secure the right of women and men to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice. The United States of America is the largest individual country donor to what the United Nations (UN) calls “international population assistance”, contributing 43% of all funds for family planning, maternal and child health care and sexually transmitted diseases, including HIV/AIDS.

However, one of the first actions taken by George W. Bush on becoming President of the United States of America was to restore the “Mexico City Policy”, which lays down that United States federal foreign assistance funds cannot be granted to foreign NGOs performing abortion or lobbying to make abortion legal. The impact of the Mexico City Policy has translated into loss of considerable funding for international NGOs unable or unwilling to submit to its restrictive interpretation. Ironically, the impact of the Mexico City Policy thus is the opposite of its intention: as clinics close and access to reproductive services becomes more difficult for lack of funding, less poor women in Europe and worldwide can afford contraception, leading to an increase in unwanted pregnancies – and consequently abortions, many of them unsafe. This, again, drives up the maternal mortality rate.

The Assembly should call on the governments of member states to take a number of measures to reverse this negative impact of the “Mexico City Policy” on the free choice of contraception in Europe. They should ensure that, in their own countries, sex education, reproductive health and family planning services are guided by the Cairo programme of action and the Ottawa Statement of Commitment; that priority is given, in their international development policies, to the allocation of funds to those organisations which have lost funding as a result of the Mexico City Policy; and that the United States of America are engaged in an informed debate about the nefast impact of the reinstatement of the Mexico City Policy worldwide, but especially also in Council of Europe member states, and are encouraged to rescind it.

I.       Draft resolution

1.        The World Health Organisation (WHO) estimates that, every year, over 500.000 women die worldwide as a result of pregnancy related causes; seven million more become ill or disabled. In addition, some 40 million abortions occur each year, often under unsafe conditions – claiming some 70.000 extra female lives. In the developing world, pregnancy and childbirth remain the greatest single threat to a woman’s health in her reproductive years.

2.        Contrary to popular belief, Europe is also concerned by this blight. The Regional Office for Europe of the World Health Organisation has set the target of less than 15 maternal deaths per 100.000 live births. Several Council of Europe member states still experience difficulties in reaching this target.

3.        In 1994, 172 countries agreed on a 20 year programme of action at the Cairo United Nations International Conference on Population and Development (ICPD). This programme of action recognised the right of women and men to “be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice”. The Cairo Programme of Action was confirmed and strenghtened in 1999. In November 2002, parliamentarians from all over the world, including members of the Parliamentary Assembly, met at Ottawa to consider and promote the implementation of the Cairo programme of action, adopting the “Ottawa Statement of Commitment”.

4.        Several international organisations and NGOs are working hard to realise the Cairo programme of action and the Ottawa Statement of Commitment. The United States of America is the largest individual country donor to what the United Nations (UN) calls “international population assistance”, contributing 43% of all funds for family planning, maternal and child health care and sexually transmitted diseases, including HIV/AIDS. However, one of the first actions taken by George W. Bush on becoming President of the United States of America was to restore the “Mexico City Policy”.

5.        The “Mexico City Policy” lays down that United States federal foreign assistance funds cannot be granted to foreign NGOs performing abortion or lobbying to make abortion legal even if foreign NGOs use their own non-US funds to perform legal abortions or to provide counselling and referral for abortion, or engage in the abortion policy debate. This policy was first announced at the 1984 UN International Conference on Population in Mexico City during Ronald Reagan’s Presidency, rescinded by President Bill Clinton in 1993, and is again in force now. Its restrictive interpretation means that all foreign NGOs have to ensure that abortion and family planning remain completely separate and independent of one another to avoid loosing US federal funds.

6.        In no case should abortion be promoted as a method of family planning. But in circumstances where abortion is not against the law, such abortion should be safe and accessible. This both avoids the health complications (and deaths) arising from unsafe abortions and allows direct access of family planning counsellors to women who have recently undergone an abortion (to help them avoid another unwanted pregnancy). The goal of a successful family planning policy must be to reduce the number both of unwanted pregnancies and abortions.

7.        The impact of the Mexico City Policy has translated into loss of considerable funding for international NGOs unable or unwilling to submit to its restrictive interpretation. The International Planned Parenthood Federation (IPPF) reports losses of millions of dollars for its member Family Planning Associations, especially in the developing world – but also, for example, in Albania, Serbia and Montenegro (especially in Kosovo), Moldova and the Russian Federation. Even international organisations, such as the UN Population Fund (UNFPA) and the WHO have been hit. While some European governments have stepped up their donor aid in response to the reinstatement of the Mexico City Policy, they have not been able to bridge the entire gap.

8.        Ironically, the impact of the Mexico City Policy thus is the opposite of its intention: as clinics close and access to reproductive services becomes more difficult for lack of funding, less poor women in Europe and worldwide can afford contraception, leading to an increase in unwanted pregnancies – and consequently abortions, many of them unsafe. This, again, drives up the maternal mortality rate.

9.        The Parliamentary Assembly thus calls on the parliaments and governments of its member states:

II.       Explanatory memorandum by Mrs Zwerver, Rapporteuse

A.       Introduction

1. The Mexico City Policy, also known as the Global Gag Rule, is a policy of the US administration which cuts funding to any organisation outside the United States which is involved in any abortion-related activity. It is important to understand that such funding is not to provide abortions per se (the US has prohibited use of its funds for abortion provision since the 1970s), but rather the funding of related activities such as counselling and/or referral and lobbying to make abortion legal of any organisation involved in such activities, even when these activities are funded by other donors.

2. When one considers that over 500.000 women die each year as a result of pregnancy related causes and over 70.000 as a result of unsafe abortions, such a decision by the US administration is bound to have a tremendous impact on women’s health, which should be of great concern to us – especially as the US is the single largest donor to international development, and by far the largest donor to international family planning. The adoption of such a position is bound to have an impact on the efforts of European donors in meeting development objectives. Moreover, it will have a definite impact in the countries which are recipient of international development aid, and more particularly on the most vulnerable groups in those countries, namely poor women. After all, in the developing world, pregnancy and childbirth remain the greatest single threat to a woman’s health in her reproductive years.

3. Contrary to popular belief, Europe is also concerned by this blight of maternal ill-health. The Regional Office for Europe of the World Health Organisation has set the target of less than 15 maternal deaths per 100.000 live births. Several Council of Europe member states have difficulties reaching this target. I do not have recent data available for all Council of Europe member states, but, in 1995-1997, (in order of severity of the problem) Russia, Romania, Georgia, Azerbaijan, Moldova, Latvia, Ukraine, Armenia, Albania, Lithuania and Slovenia were all cited as having failed to reach this target1.

4. Therefore, the report will look into the real impact of the imposition of the Mexico City Policy specifically on women’s health in Europe and world-wide, and on the capacity of family planning organisations to provide much needed services. Another important aspect to investigate is the political impact of this policy, particularly in light of the recent increasingly problematic position of the US administration regarding all aspects of international family planning and women’s health and rights. Finally, the report will conclude with an overview of what European countries have been doing to respond to the Mexico City Policy and also make suggestions for what Council of Europe member States could consider doing.

5. I will rely to a great deal on the excellent expert paper2 prepared by Mrs Dilys Cossey (United Kingdom), which has been declassified and is available from the Committee Secretariat.

B.       Background of the Mexico City Policy

6. In 1994, 172 countries agreed on a programme of action at the Cairo United Nations International Conference on Population and Development (ICPD). This programme of action (see document AS/Ega/Inf (2003) 11) recognised the right of women and men to “be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice”. The principles underlying the Cairo Programme of Action consensus affirm the application of ‘universally recognized human rights standards to all aspects of population programmes’3 and state that ‘The human rights of women and the girl child are an inalienable, integral and indivisible part of universal human rights’4. The programme of action includes a comprehensive definition of reproductive rights and reproductive health, (Chapter VII) and pays particular attention to the importance of women’s and children’s health (Chapter VIII).

7. In November 2002, parliamentarians from all over the world, including members of the Parliamentary Assembly, met at Ottawa to consider and promote the implementation of the Cairo programme of action, adopting the “Ottawa Statement of Commitment” (see Appendix II).

8. Several international organisations and NGOs are working hard to realise the Cairo programme of action and the Ottawa Statement of Commitment – the UN Population Fund (UNFPA), the World Health Organisation (WHO), international NGOs “International Planned Parenthood Federation” (IPPF) and “Marie Stopes International” (MSI) and the United States NGO “Ipas”, to name but a few. The United States of America is the largest individual country donor to what the United Nations (UN) calls “international population assistance”, contributing 43% of all funds for family planning, maternal and child health care and sexually transmitted diseases, including HIV/AIDS. However, one of the first actions taken by George W. Bush on becoming President of the United States of America was to restore the “Mexico City Policy”.

9. The “Mexico City Policy” lays down that United States federal foreign assistance funds cannot be granted to foreign NGOs performing or lobbying to make abortion legal even if this hampers NGOs’ ability to help women exercise their reproductive rights. This policy was first announced at the 1984 UN International Conference on Population in Mexico City during Ronald Reagan’s Presidency, rescinded by President Bill Clinton in 1993, and is again in force now. Its restrictive interpretation means that all foreign NGOs have to ensure that abortion and family planning remain completely separate and independent of one another to avoid loosing US federal funds; this hampers NGOs’ ability to help women make the transition to modern contraception. I consider that the reinstatement of the Mexico City Policy compromises the clear principles of the Cairo Programme of Action and the Ottawa Statement of Commitment, by bringing into the international arena the contradictions, complexities and confusions of the debate on abortion in America and its influence on domestic policies.

C.       Impact of the Mexico City Policy

On women’s health

10. As mentioned before, the World Health Organisation (WHO) estimates that every year half a million women die as a result of pregnancy or pregnancy-related causes; millions more become ill or disabled. Some 70,000 women die every year from unsafe abortion, 13% of all maternal deaths5. The remorseless toll of maternal death has been compared to a jumbo jet crashing every six hours day in day out. Most of these deaths are in the developing world. The 1994 Cairo Programme of Action called for a reduction by one half of the 1990 levels of maternal mortality by the year 2000 and a further one half by 20156. But UNFPA states that, while many health indicators have improved over the last two decades in most of the developing world, maternal mortality rates and ratios have not declined. Dr Nafis Sadik, former UNFPA Executive Director, has stated that pregnancy and childbirth is the greatest single threat to a woman’s health during her reproductive years7.

11. In the view of our expert, Mrs Cossey, the reinstatement of the Mexico City Policy and the imposition of restrictions on reproductive health NGOs engaged in abortion activities will ensure that these targets remain distant. The one permitted area of operation is that of Post Abortion Care (PAC), which limits itself to repairing the damage done to women after spontaneous, unsafe or illegal abortions. USAID funding for PAC began in 1990 and to date some $20 million has been spent on the programme, of which $15 million was spent in 1999 and 2000. An evaluation carried out by USAID in October 2001, while demonstrating the positive contribution made to reductions in hospital maternal mortality by PAC programmes in three of the four countries studied, also showed that follow-up with family planning advice and services and linking with other reproductive health services which were also part of the PAC programme, were weak and needed strengthening.8 Such links are essential for the PAC programme to be fully effective; on its own, it is not enough. The Cairo Programme of Action defined reproductive health care in as a ‘constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems’ 9

12. The weakness of this approach is that it does nothing to protect women’s lives and health by helping them have access to safe abortion. It is a policy cleverly based on only part of the Cairo consensus on abortion embodied in paragraph 8.25 of the Programme of Action10 which states “In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organisations are urged to strengthen their commitment to women’s health, to deal with the impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services.”

13. Our expert thinks that post abortion care may well satisfy the conscience of the current leaders in the United States, but the message it carries is that unsafe abortion is acceptable as long as women can have ‘quality services for the management of complications from abortion’. This is not the overall sense of the Cairo abortion consensus, which was long and closely argued and in which the then US delegation played a leading and constructive role. This consensus laid heavy emphasis on the need for effective reproductive, maternal and child health services to offer the full range of choices11. It was further developed in the statement from the UN General Assembly Special Session (UNGASS) on the five-year follow-up to the International Conference on Population and Development (ICPD) in June/July 1999 which stated ‘… in circumstances where abortion is not against the law , health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible…’12.

14. The end result for any USAID funded population and reproductive health programmes in, for example, Eastern European countries is that NGO – and possibly also government – reproductive and sexual health services will be fragmented and isolated from abortion services, except in the case of post abortion care. Abortion is legal in all these countries and family planning services are inadequate; women rely on abortion for regulating their fertility. Only by improving family planning services, as a priority, will this reliance on abortion decrease; yet, ironically, NGOs providing family planning where abortion is legal and where there are no subsequent complications are not eligible for USAID funding. In effect, slice by slice the effectiveness of reproductive and sexual health services is being gradually eroded by imposition of restrictions by and ideology of US Government policy.

On organisations providing family planning activities and involved in abortion-related activities

15. The impact of the Mexico City Policy can be seen most clearly in two areas: an insidiously negative influence on the climate of opinion relating to reproductive and sexual health services; significant loss of funding for NGOs with a resulting – sometimes rapid - reduction of programmes and services.

16. Imposing unrealistic funding constraints on NGOs is particularly short-sighted. NGOs play a unique role in those challenging areas, in which it is difficult for governments to operate, for example in the provision of information, education and services for young people. NGOs can pioneer approaches and, from their grass-roots perspectives, identify needs. But the Mexico City Policy limits their operational choice and their ability to respond to people’s needs.

17. The Mexico City Policy can influence the climate of opinion and engender cautiousness and uncertainty for fear of losing funding. In their article The Mexico City Policy and US Family Planning Assistance, Richard P Cincotta and Barbara B Crane13 cited evidence from research carried out in 1990 by the USAID-funded Population Technical Assistance Project. This was the most carefully documented evaluation of the Mexico City policy first time round and 49 subproject sites in six developing countries were visited. Results revealed, in some cases, clients in medical need being turned away or left uninformed of their condition; efforts to treat septic abortion left out of projects or discontinued; physicians working at NGOs being told they could not perform legal abortions in their independent private practice; and staff prohibited from conducting research on the local incidence of abortion or from discussion of abortion in the workplace or at conferences.

18. It looks as though history is already repeating itself. Six US NGOs, spearheaded by leadership of Population Action International are currently gathering qualitative data in four countries (Ethiopia, Kenya, Zambia and Romania) on the impact of the Global Gag Rule on access to family planning services and supplies. Visits have been made to all four countries. Early results suggest that family planning services have been curtailed (severely so in Zambia); clinics have been closed in Kenya; community-based distribution of services and contraceptives, reproductive health and HIV information and referrals have been hit particularly hard. In Romania the main impact appears to be to ensure that abortion and family planning remain completely separate and independent of one another, thus hampering NGOs’ ability to help women to exercise their reproductive rights. The research findings will be written up as case studies for each country and will be ready in the summer of 200314. An earlier indication from Romania of the uncertainty generated by the Mexico City Policy was the cancellation of a project for the US NGO Ipas to work with the government to give women family planning after abortion. The reason was ‘contractors there got scared about the gag rule. People are just staying away from abortion-related issues’. 15

19. Further evidence of the Mexico City Policy’s spreading influence is the US Government’s discouragement of attention to the problem of unsafe abortion or airing of any perspectives by USAID-funded NGOs that might be seen as contrary to the Administration’s anti-abortion policy. Abortion-related information is increasingly difficult to find on the websites of international health organisations receiving funding from USAID and USAID-supported Safe Motherhood and other reproductive health initiatives are avoiding attention to abortion-related maternal mortality16.

20. It is important to remember that this is the second time that some NGOs have had this experience, for example the International Planned Parenthood Federation (IPPF). In November 1984 IPPF lost an annual $12 million grant with $5 million in commodities as a result of its refusal to comply with the new Mexico City Policy - one quarter of its income. IPPF is a unique organisation. Set up over 50 years ago it has now has over 150 autonomous member national family planning associations and is working in 182 countries. Based on this unrivalled knowledge of global reproductive and sexual health issues, IPPF is committed to a woman’s right to choose legal abortion. Currently eight of its member FPAs are involved in abortion-related activity. Thus, IPPF cannot agree to the restrictions imposed by the Mexico City Policy and has not signed.

21. However, in 2000 IPPF had already started losing funding as a result of President Clinton’s having to agree to the year-long reinstatement of the Mexico City Policy. For the two years 1999-2001 its USAID funding was $10.5 million, less than 8% of its total income. For 2001-2003 IPPF it is losing $8 million, which would have covered a Grant Extension focussing on activities such as youth programmes, HIV/AIDS and advocacy. Successful current programmes which could be cut include such examples as youth-friendly centres in Ghana, Senegal and Mozambique, technology for providing information for young people in Peru and Albania and capacity building programmes in Mozambique, Senegal and South Africa17.

22. The experience of Marie Stopes International (MSI) is a vivid illustration of how brutal the impact of the Mexico City Policy can be. Working in 38 countries across Africa, Asia, Australia, Europe, Latin America and the Middle East, MSI provides sexual and reproductive information to 3.3 million people worldwide. When MSI refused to sign the Mexico City Policy it lost more than $3 million income in Africa, resulting in the closure of 3 clinics in Kenya, outreach programmes serving poor communities in Ethiopia and further centres in Tanzania. ‘Given the current difficult economic circumstances in Kenya, the loss of USAID funding has come as a complete body blow to Marie Stopes Kenya” said MSI’s Africa Regional Director, Ms Sue Newport18.

23. The Mexico City policy has also touched the US NGO Ipas. Set up in 1973, Ipas is an international non-governmental organisation that works to reduce abortion-related deaths and injuries; increase women’s ability to exercise their sexual and reproductive rights; and improve access to reproductive health services, including safe abortion care (postabortion care and induced abortion). Ipas’s global and country programmes include training, research, advocacy, distribution of reproductive health technologies and information dissemination. Ipas manufactures and distributes high quality manual vacuum aspiration (MVA) instruments and is widely respected for its research and expertise. At the time of the reinstatement of the gag rule, Ipas was working as a subcontractor under a USAID project with the University of North Carolina (UNC) to support training and technical assistance in post abortion care. In order not to implement the gag rule restrictions on overseas NGO partners Ipas withdrew from the project. – and lost up to $2 million. But, equally important, activities in several African countries were disrupted while UNC looked for other partners and some activities in the early stages for other countries never materialised. Ipas’s unique expertise was lost to the project and to the local country counterparts who had relied on Ipas technical assistance.

On intergovernmental bodies

24. The UN Population Fund (UNFPA) has also suffered significant loss of funding through the Bush administration’s exercise of its powers under the Kemp-Kasten amendment contained in the annual appropriations bill that has to be renewed every year. Even under the Clinton administration, in 2000, UNFPA’s $25 million grant had been subject to a dollar-for-dollar reduction for any amount spent in China, resulting in UNFPA only receiving about $21.5 million. At the end of 2001 Congress approved up to $34 million for Fiscal Year 2002 (FY), but the entire amount was first frozen by President Bush and then completely withheld in July 2002. This decision was taken despite the findings of a US 14-day Mission to China from 13-26 May 2002, which concluded that ‘We find no evidence that UNFPA has knowingly supported or participated in the management of a program of coercive abortion or involuntary sterilisation in the PRC’ and recommended that ‘no more than $34 million which has already been appropriated be released to UNFPA’19. A previous British fact-finding mission sent to China in April 2002 had concluded that ‘UNFPA was a force for good’ and that ‘UNFPA’s involvement appears to be encouraging reformers within China in their efforts to speed up the transition to a client-centred approach throughout China’20.

25. In November the US stated that it reserved the right to decide whether to contribute to the World Health Organisation (WHO) programme that includes research on medication that induces abortion. A complaint to the Secretary of State was made by nine members of Congress that some $3 million for

the WHO Human Reproduction Programme had been frozen. A spokesman for the State Department said that it had not been frozen but ‘we haven’t defined exactly where it (the $3 million) is going to be spent. It’s available to be spent on reproductive health activities that are consistent with US law21.

On Donor Governments in Europe and their partners

26. Poul Nielson, the European Union Commissioner for Humanitarian and Development Aid, summarised the spirit of European donor reaction to the reinstatement by the Bush administration of the Mexico City Policy in his phrase that Europe should fill the ‘decency gap’. This spirit was strongly echoed by European Government donors, such as Denmark and the Netherlands.

27. Their actions have justified these words. By July 2001 Germany, the Netherlands, Denmark and Finland had responded to the IPPF’s approaches and increased their Government contributions to IPPF core funding by the following amounts (the Netherlands doubled their contribution) 22:

Germany:        2001:       Euro 511,292 extra Euro 460,163 per year

Netherlands       2001-2003       Euro 20.4 million

Denmark:        2001:        Euro 268,916 extra

Finland:       2001       Euro 84,000 extra

28. In 2002 UNFPA also experienced an increase in European donor funding (thirteen of the 19 donor countries increasing their contribution were European) The Netherlands is its largest contributor ($52.5 million), followed by Norway ($25.15 million), UK ($21.68 million), Denmark ($21.46 million) and Germany ($13 million)23. In her January 2003 statement to the Executive Board of the UN Development Programme and UNFPA Thoraya Ahmed Obaid, UNFPA Executive Director, reported that in 2002 UNFPA’s core resources totalled $256 million, just $13 million less than the $269 million received in 200124.

29. Sweden allocates around 4% of its ODA (Official Development Aid) to issues in the field of population and development. In view of UNFPA’s difficult situation, and given Sweden’s favourable assessment of the Fund’s work, the Swedish government also increased its core contribution to it by SEK 25 million in 2002. In 2003, Sweden further increased its core contribution by SEK 20 million to now SEK 205 million. Sweden is also a strong supporter of UNICEF, UNAIDS and the IPPF.

30. In July 2002 Poul Nielson announced a Euro 32 million programme in 22 developing countries in partnership with UNFPA and IPPF – thus fulfilling his promise to fill the ‘decency gap’. Calling the US decision ‘regrettable and counter-productive ’ Mr Nielson said ‘the losers from this decision will be some of the most vulnerable people on this planet. Reproductive health services are crucial elements in the fight against poverty…’25.

31. It is important to note that the USA remains the largest single country contributor to reproductive and sexual health in development. Nevertheless, donors from Europe contribute 40% of aid to population, sexual and reproductive health activities. However, six of 18 European donors do not have a population, sexual and reproductive health element in their international development budget26.

32. The continuing challenge is, however, to build on this goodwill and not just to sustain but to continue to increase this support. There is scope for significant increase in view of the fact that, as indicated in paragraph 32, six of 18 European donors do not have a population, sexual and reproductive health element in their international development budget. These donors should be encouraged to review their policy as a priority. The need for investment is urgent; the resource targets set by the Cairo Programme of Action ($17 billion for 2005; $18 billion for 2010 and $20 billion in 2015)27 are both too low and not being met.

33. Moreover, in November 2001, the EU Development Council agreed to give the European Commission competence to monitor the progress of EU Member States in meeting the UN target of allocating 0,7% of GNP to ODA. The European Commission is expected to open a dialogue with EU Member States and set a timetable for reaching this target. The Assembly could usefully play a role in this monitoring by looking into coordination with non-EU donor and potential donor countries. Moreover, national parliamentarians could play an essential role in following up the monitoring process28.

D.        Conclusions

34. I think that in no case should abortion be promoted as a method of family planning. But in circumstances where abortion is not against the law, such abortion should be safe and accessible. This both avoids the health complications (and deaths) arising from unsafe abortions, and allows direct access of family planners to women who have recently undergone an abortion (to help them choose a more appropriate method of family planning). The goal of a successful family planning policy must be to reduce the number both of unwanted pregnancies and of abortions in the first place.

35. The impact of the Mexico City Policy has translated into loss of considerable funding for international NGOs unable or unwilling to submit to its restrictive interpretation. The International Planned Parenthood Federation (IPPF) reports losses of millions of dollars for its member Family Planning Associations, especially in the developing world – but also, for example, in Albania, Serbia and Montenegro (especially in Kosovo), Moldova and the Russian Federation. Even international organisations, such as the UN Population Fund (UNFPA), and the WHO have been hit. While some European governments have stepped up their donor aid in response to the reinstatement of the Mexico City Policy, they have not been able to bridge the entire gap.

36. Ironically, the impact of the Mexico City Policy thus is the opposite of its intention: as clinics close and access to reproductive services becomes more difficult for lack of funding, less poor women in Europe and worldwide can afford contraception, leading to an increase in unwanted pregnancies – and consequently abortions, many of them unsafe. This, again, drives up the maternal mortality rate.

E.        Recommendations

37. I think that the Parliamentary Assembly thus calls on the governments of its member states:

APPENDIX I:       Case study - Armenia

Fact-finding mission of Mrs Zwerver to Armenia (24-28 March 2003, Yerevan)

Introduction

1. Mrs Zwerver went on a fact-finding mission to Armenia from 24 to 28 March 2002, accompanied by Ms Olga Kostenko, Co-Secretary of the Committee. The programme of the visit was prepared in co-operation with the Family Planning Association of Armenia (FPA) and its Executive Director Mrs Mary Khachikyan, whose help was very precious.

2. The programme of the mission included meetings with governmental and parliamentary officials, representatives of international organisations and non-governmental organisations working in the fields of family planning and reproductive rights, as well as visits of health care institutions.

3. The visit of Senator Zwerver was covered by Armenian TV news programmes and several major newspapers.

General situation

4. Mrs Zwerver was welcomed and briefed on the situation in the country by the Family Planning Association of Armenia "For Family and Health" (FPA of Armenia), which is a non-governmental, not-for-profit public organisation. The FPA of Armenia became a member of the International Planned Parenthood Federation (IPPF) and it's European Network in 1999. The organisation has 9 affiliate branches and representative offices throughout Armenia. Its main goals are to a) advance the basic human rights of all women, men and young people, to make free and informed choices regarding their own sexual and reproductive health, b) to advocate in favour of the means to exercise this right and c) to ensure that women’s equality and rights to family planning, sexual and reproductive health remain a priority in national and international development policies.

5. The members of FPA pointed out that the transition period in Armenia resulted in the crisis of social-economic and cultural life in the country, and consequently the situation of women has worsened. The result is a high rate of migration, poverty, and unemployment which in turn has led to the impossibility for women to fully realise their reproductive rights.

6. The following obstacles stand in the way of improving women's health:

-       low living standards;

-        health care facilities’ poor budget;

-       lack of a clear state policy directed to the effective development of health;

-       unemployment - lack of social welfare;

-       unavailability of free medical services.

7. The State health service now run on a fee basis is paid now and no social security coverage is provided to the population.

8. At present, the rate of childbirth has decreased, connected with the above-mentioned points as well as with a high rate of migration (including of men).

9. The number both of single mothers and women who leave their children has increased. Growth of prostitution may be observed among juveniles as well, and a new phenomenon - trafficking in women - has appeared. As a result the number of sexually transmitted diseases, pregnancy among teenagers, and illegal abortions has increased.

10. Abortion and contraception are legally permitted in Armenia. Induced abortion is one of the most popular methods of contraception. This is partially connected with the sexual ignorance of women as well as with the unaffordability of contraception.

11. The other method of contraception is coitus interruptus, and only a small part of women use condoms and intrauterina devices because they have to pay for them (according to an Armenian social survey).

12. As it is indicated in the 2000 Armenia Demographic and Health Survey, there are increasing trends towards beginning antenatal care late and giving birth at home. Armenia also has a high rate of induced abortion, an average of 2,6 abortions per woman over her lifetime.

Impact of the “Global Gag Rule” on Armenia

13. The FPA representatives informed Mrs Zwerver that the FPA was not working directly with USAID and its funding was not effected by the cuts on abortion-related activities.

14. Mr Daduryan, United Nations Population Fund (UNFPA) programme officer informed Mrs Zwerver that UNFPA has been working in Armenia since 1997 in close co-operation with the Government. 200 000 USD to 300 000 USD are provided by the UNFPA to Armenia each year on reproductive rights programmes. They work in co-operation with other donors, but in general donors interest in this country was not very high.

15. He considered that the Global Gag Rule had no direct impact on the reproductive health programmes in Armenia, but had definitely effected the budget of UNFPA, which was reduced up to 40% in some countries. Nevertheless, so far the UNFPA had been successful in protecting its programmes in Armenia.

16. He also mentioned that money accorded by the USAID to reproductive rights programmes were distributed through different American organisations and, therefore, were not used very effectively.

17. The first priorities in the reproductive rights programmes should be given to the purchasing of medical equipment, contraceptives, financing of informational campaigns and support to the governmental priorities.

18. UNFPA gives 30% of their money to local NGOs, 30% to the Government and 20 % to their administrative needs; the rest of the funds are used to support 77 consultation cabinets with medical equipment. In comparison to the Soviet time, when 3 billion USD had been spent for health care, now the budget could offer only 400 million USD.

19. In the discussion with the members of Parliament it was mentioned that USAID had supported the national anti-AIDs programme and had provided assistance for legislative development and the publication of international conventions and other related documents.

20. During the meeting with NGOs, several representatives of these organisations stated that they had been involved and continued co-operation in different projects financed by USAID, such as PRIME II (a partnership combining leading global health care organisations dedicated to improving the quality and accessibility of family planning and reproductive health care services throughout the world) and the “Reproductive Sexual Rights and Gender Violence” project. The implementation of these projects was successful and efficient. However, the project on family planning conducted by John Hopkins University and financed by USAID was strongly criticised by the society and created difficulties concerning the adequate understanding of family planning problems by Armenians. Such a reaction had been provoked by the advertising campaign for this project, which was not adapted to the particular situation in the country.

21. In September 2002 the Ministry of Health and the PRIME II project, with support from USAID, organised a Forum on Improving Quality of and Access to Reproductive and Child Health Care. The Forum made policy and programme recommendations to the Ministry of Health for action to strengthen health services.

22. In general, as it was stated by Mr Abrahamyan, Consultant to the Minister of Health on Maternal Child Issues the projects financed through USAID partner organisations spent their money on administrative needs and only a small amount of money went directly to the country, while UNFPA had

developed a very efficient approach to the elaboration of their programmes. They took into consideration local needs and implemented their programmes with local partners.

Sexual education

23. The FPA organised several meetings of Mrs Zwerver with mass-media and non-governmental organisations. The representatives of the NGOs especially highlighted the problem of sexual education in Armenia. Presently only two health facilities in the city of Yerevan (created by the AFHA) provide free FP/SRH counselling and health care services to young people. The lack of communication and the economic constraints made it difficult for young people from rural areas to travel to Yerevan and benefit from those services at the optimum level. The counselling on STIs/HIV was provided mainly at the STI and AIDS Centres, however, young people had very limited access to those facilities mainly due to the cultural stigma associated with the sexuality of adolescents. Thus, sexual and reproductive health-related needs of adolescents and people of reproductive age were left unprotected and un-addressed.

24. The representatives of the Youth Forum of FPA informed Mrs Zwerver on their activities related to sexual and reproductive rights education in the regions of Armenia.

25. They had organised a seven day training-seminar for young peer educators in reproductive and sexual security rights. Young people expressed their needs in exchanges with partner organisations from other European countries. They also insisted on the co-operation of the government with NGOs in the implementation of reproductive rights. Young people should also be represented at the international conferences dealing with the problem of reproductive rights in order to represent their position and have a possibility of participating in international exchanges.

26. Very interesting was the position of Bishop Paren Avedikian, the representative of the Armenian Apostolic Church, regarding the problem of health care for women and unsafe abortions. He said that his Church had never condemned contraception and would support sexual education in schools.

27. Mr Yeritsyan and Mr Tadevosyan, members of the Armenian Parliament, informed Mrs Zwerver about the adoption by the Parliament of the Law on reproductive health and reproductive rights. This law gave women the right to decide freely and responsibly on the number and spacing of their children. Abortion was legal and it also stated that sexual education should be provided in schools and other educational establishments. Unfortunately, few funds were available to implement it.

Sexually transmitted diseases

28. As it was stated my the members of Parliament, the most dangerous problems related to family-planning and reproductive rights were the increase of sexually transmitted infections and abortions and the limited access of population to health care services.

29. Mrs Yeritsyan said that the Parliament had developed a programme for 2003 approved by the government on the support to health care services for women in rural areas. Regional medical establishments provided low quality services and because of migration the spread of STI and HIV/AIDs diseases has significantly increased.

30. Mr Yesayan, Deputy Minister of Social Affairs and Mr Abrahamyan Consultant of Minister of Health on Maternal Child Issues said that sexually transmitted infections created a great danger for the population of Armenia.

31. Starting from 1988 and up to the end of 2001, in total 169 cases of HIV carriers had been officially registered in Armenia, and 19 of them had already died. However, according to UN data, the estimated number of HIV carriers was about 1500-2200, and most of them were young persons. The main background factors were the lack of sex education, increased migration, and the limited access to preventive and curative medical services.

Governmental policy

32. In the discussion with the representatives of the government, Mr Yesayan, Deputy Minister of Social Affairs, and Mr Abrahamyan, Consultant to the Minister of Health on Maternal Child Issues, Mrs Zwerver was informed on the present situation in Armenia regarding reproductive health and governmental policy on family planning and reproductive rights.

33. The national budget allocation for the Ministry of Health was extremely poor, and there were plans for even further cuts. There was a vicious circle in the system of the Health Service: neither the people nor the government disposed of enough funds to pay medical services.

34. The government had no resources to implement the Law on reproductive rights and asked international donors to help with the financing. The government had no resources to support the NGOs which were working in this area, but was willingly co-operating with them.

35. Another important problem was that there were no national educational programs in the field of health care, particularly sexual health.

36. A National Program of Family Planning had been implemented in Armenia in the framework of which a large number of contraceptives had been supplied. The program was supported by UNFPA.

37. The government of Armenia had launched an ambitious programme to expand primary health care through the introduction of family medicine and more efficient service delivery mechanisms.

38. The resources for family planning activities should be invested first of all into technical equipment for the State health services, then to training of health care providers, especially in the regions and to the public awareness campaigns and the improvement of the access to health care facilities.

Recommendations

39. As a result of this mission Mrs Zwerver suggests several recommendations aimed at the improvement of the situation in Armenia regarding reproductive rights and a family planning policy:

APPENDIX II:       2002 International Parliamentarians' Conference


on the implementation of the Programme of Action of the International Conference on Population and Development (ICPD)

Ottawa Commitment

We Parliamentarians from all over the world come to Ottawa to reaffirm our commitment to the Programme of Action of the International Conference on Population and Development and to commit ourselves to action to advance the implementation of the Programme of Action and of the key actions identified in its five-year review.

We further reaffirm our commitment to sustainable development and its three pillars of economic growth, social progress and environmental protection.

We recognize, and accept, our crucial role, both individually and collectively, as the bridge between people and government -- as advocates for the rights and needs of the people, as legislators to make laws to protect these rights and as policy makers to mobilize the resources and create the enabling environment needed to address these needs.

We further recognize, and accept, population as a cross-cutting issue affecting all other development issues and thus as indispensable in achieving the Millennium Development Goals, in particular those aimed at eradicating poverty and hunger; improving maternal health, including efforts to combat unsafe abortion and promote sexual and reproductive health and rights; combating HIV/AIDS; providing universal primary education; and promoting gender equality and women's empowerment.

We further recognize the following:

There is a 34 per cent shortfall in meeting the agreed global resource target for 2000 of $17 billion for population and reproductive health programmes -- 24 per cent in domestic resources and approximately 55 per cent in external resources.

Half of all people in the world live on less than $2 per day; 1.2 billion people live on less than $1 per day. More than half of these are women.

Political instability impedes poverty eradication and sustainable development.

Worldwide, some 840 million people are malnourished; millions of them, including 6 million children under the age of 5, die each year from the effects of chronic hunger and malnutrition.

There are currently an estimated 40 million refugees and internally displaced persons, many of whom are without access to reproductive health services.

In 2000, 508 million people lived in water-stressed countries; by 2025, 3 billion people will be living in such countries.

There are 1 billion adolescents who are in or are about to enter their reproductive years, many of whom have no access to reproductive health education and services.

Each year, over 500,000 women die during pregnancy and childbirth; another 7 million suffer infection or injury.

Worldwide, 350 million women are denied access to a range of safe and effective contraceptives; each year, nearly 175 million pregnancies are unwanted or ill-timed.

The reproductive health and family planning needs of millions of women throughout the world have been ignored, in particular in countries such as Afghanistan, where women have been forced to endure such unmet needs for decades.

Close to 40 million abortions occur each year, often under unsafe conditions. Some 78,000 women, or 227 a day, die every year as a result of unsafe interruptions of pregnancy.

In 2001, 5 million people became infected with HIV; 800,000 of them were children; 3 million people died of AIDS that same year.

There are 13.4 million AIDS orphans, many of whom are heads of households.

Half of all new cases of HIV infection are among young people aged 15-24, with girls at particular risk.

There are 40 million people living with HIV/AIDS; 28.5 million of them are in Africa.

There is an annual 8 billion shortfall in condoms needed to provide protection against HIV/AIDS.

By 2050, the number of persons aged 60 years and over will increase from 600 million to almost 2 billion, and the proportion of such persons will double from 10 per cent to 21 per cent, many of whom will live in poverty and require public assistance for social and health services.

Call to action

We Parliamentarians here in Ottawa commit ourselves to the following actions and call on Parliamentarians everywhere to also commit themselves to these actions:

Pledge

We Parliamentarians pledge, as public advocates, legislators and policy makers, to carry out these actions and to systematically and actively monitor the progress we make in doing so. We further pledge to report regularly on this progress through parliamentary groups and to meet again in two years to assess the results we have made, both individually and collectively.

Reporting committee: Committee on Equal Opportunities for Women and Men

Reference to Committee: Doc 9508, reference N° 2753 of 3 September 2002

Draft resolution unanimously adopted by the Committee with 2 abstentions on 5 September 2003.

Members of the Committee: Mrs Err (Chairperson), Mrs Aguiar (1st Vice-Chairperson), Mrs Mikutiene (2nd Vice-Chairperson), Mr Baburin (alternate: Mr Rudkovsky), Mrs Bauer, Mrs Biga-Friganovic, Mrs Bilgehan, Ms Castro (alternate: Mrs Lopez Gonzalez), Mrs Cliveti, Ms Curdova, Mr Dalgaard, Ms Fogler, Mr Foulkes, Mrs Frimannsdóttir (alternate: Mr Skarphedinsson), Mr Gaburro (alternate: Mr Giovanelli), Mr Goldberg, Ms Hadjiyeva, Mrs Hägg, Mr Juri, Mrs Katseli (alternate: Mrs Damanaki), Mrs Kestelijn-Sierens, Ms Konglevoll, Mrs Kosa-Kovacs, Mrs Kryemadhi, Mrs Labucka, Mrs Lintonen, Ms Lucic, Mr Mahmood, Mr Mooney, Mr Neimarlija, Mrs Paoletti Tangheroni (alternate: Mr Scherini), Mrs Patarkalishvili, Ms Patereu, Mr Pavlov, Ms Pericleous-Papadopoulos, Mrs Petrova-Mitevska, Mr Pintat, Mr Pullicino Orlando, Mr Riccardi, Mrs Roth, Mrs Rupprecht, Mrs Schicker, Mrs Yarygina, Mrs Zapfl-Helbling, Mrs Zwerver.

N.B. The names of the members who took part in the meeting are printed in italics.

Secretaries of the Committee: Mrs Kleinsorge, Ms Kostenko


1 UNFPA Division for Arab States and Europe/WHO Regional Office for Europe, Women’s and Reproductive Health Programme: Family Planning and Reproductive Health in Central and Eastern Europe and the Newly Independent States, third edition 2000. The maternal mortality ratios cited per 100.000 live births were 50 for Russia (1997), 42 for Romania (1997), 47 for Georgia (1995), 44 for Azerbaijan (1995), 48 for Moldova (1997), 42 for Latvia (1997), 31 for Ukraine (1997), 39 for Armenia (1997), 27 for Albania (1997), 22 for Lithuania (1997) and 26 for Slovenia (1997).

2 AS/Ega (2003) 21.

3 Programme of Action adopted at the International Conference on Population and Development, Chapter 1, Preamble para 1.15.

4 Programme of Action, Chapter 11, Principles, Principle 4

5 ‘State of the World in 1999: demographic change and sustainable development’, keynote speech by Dr Nafis Sadik, then UNFPA Executive Director, Interparliamentary Conference on demographic change and sustainable development, Bucharest, Romania, 21-23 October 1999.

6 Programme of Action adopted at the International Conference on Population and Development, Chapter VIII: Health, Morbidity and Mortality, para 8.21 Cairo 5-13 September 1994.

7 Dr Nafis Sadik, Interparliamentary Conference on demographic change and sustainable development, 21-23 October 1999

8 ‘Global Evaluation of USAID’s Postabortion Care Programme’, October 2001, USAID.

9 Cairo Programme of Action, Chapter VII, Reproductive Rights and Reproductive Health, Para 7.2, 5-13 September 1994.

10 Cairo Programme of Action, Chapter VIII, Health Morbidity and Mortality, 5-13 September 1994.

11 Cairo Programme of Action, Chapter VIII, Health, Morbidity and Mortality, paras 8.17 and 8.22 5-13 September 1994.

12 ‘Key Actions for the Further Implementation of the ICPD Programme of Action – ICPD + 5’; Chapter IV, Reproductive Rights and Reproductive Health, Section C, Reducing Maternal Mortality and Morbidity, Para 63 (iii); report of the special session of the United Nations General Assembly (UNGASS) (ICPD + 5), June 1999.

13 ‘The Mexico City Policy and US Family Planning Assistance, Richard P Cincotta and Barbara B Crane, SCIENCE, Vol 294 19 October 2001.

14 GGR Impact Research, e-mail from Population Action International, 1 April 2003.

15 Welcome to Peru, where pregnancy can kill you. Randi Glatzer. Self, August 2001.

16 Information supplied by Ipas by e-mail, 20 March 2003.

17 IPPF European Network (EN) Mexico City Information Pack, July 2002.

18 www.e-politix.com/forum/mariestopes.

19 www.house.gov/maloney/issues/UNFPA/unfpausreport.pdf.

20 IEPFPD Press release 18 July 2002

21 IEPFPD News Update November 2002

22 DAC Watch, IPPF European Network, vol 4, July 2001

23 www.eurongos.org

24 www.unfpa.org

25 Press release from European Commission

26 State of the World Population Doc 9452 para 23

27 Programme of Action, Chapter X111 National Action, para 13.5

28 State of the World Population Doc 9452 para 27