By: Adrienne Germain, President Emerita, International Women’s Health Coalition
Published: October, 2016
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Purpose and Structure
This essay is a guide to International Women’s Health Coalition (IWHC) materials on sexual and reproductive rights and health (SRRH) housed in the Sophia Smith Collection at Smith College. It describes how IWHC and our international colleagues created the foundational ideas for SRRH services, programs, and policy advocacy in and for the South.
The Background section briefly describes why IWHC expanded IWHC’s mission from abortion access to SRRH, and describes IWHC’s strategy for creating ideas and evidence needed to position SRRH at the center of international and national population and health policies and programs. The second and third sections of the essay, “Defining and Refining the SRRH Concept” and “Elaborating Selected Components of SRRH,” present the substantive materials created through IWHC’s collaborations with feminist advocates, especially from the South, and with mainstream population and health professionals. The final section reflects on progress toward SRRH since 1994 and the challenge ahead.
From the late 1960s onward, international population policy aimed to reduce population growth in developing countries by providing modern contraceptive methods to the largest possible number of married women ages 15-49. The population sector used dedicated funds, demographers, and specialized global and national institutions to drive this agenda. Concurrently, the health sector’s “maternal and child health” (MCH) initiatives, including family planning, approached maternal health narrowly and primarily as a means to achieve child health. Together, the two sectors fell far short of addressing women’s health and human rights (Presser, 1997; Dixon-Mueller et al., 2000).
From 1968 to 1985, women of all ages and life circumstances in villages and slums across Africa, Asia and Latin America told me their concerns about unwanted pregnancies and death and injury in childbirth, vaginal discharge and infertility (much of which resulted from undiagnosed or untreated sexually transmitted infections, “STIs”), and sexual, emotional and physical violence. These conversations and many others with policy makers, researchers and health care providers also revealed lack of quality health services for women. National family planning programs commonly did not provide accurate information or sufficient contraceptive choices; some violated women’s right to fully informed and free consent. Maternal health services, generally inaccessible and disrespectful, especially toward disadvantaged women, focused on antenatal care and normal deliveries attended by health workers without skills and facilities to handle complicated pregnancy and delivery. Safe abortion was rarely provided even where legal, and STIs and violence against girls and women were ignored everywhere.
The population sector interpreted the emerging demand for women’s health and rights as an existential threat to their identity and autonomy. They feared that embedding family planning in health services would result in lower priority for, and medical restrictions on, contraceptive access. They believed that broadening their clientele beyond married women, encouraging sex education, and advocating for or providing safe abortion would fuel political opposition to contraception. Some argued that population control, a social good, had precedence over individuals’ health and rights. Health sector leaders asserted that integrated services for pregnancy prevention, abortion, maternal health and STIs were beyond the capacity and resources of health systems in Southern countries. Although some population and health policy makers acknowledged research that demonstrated the pivotal relationship between women’s fertility, health and investments in their human capital such as education, the population and health sectors did not champion such investments.
In 1985, IWHC’s President, Joan Dunlop, and I decided to create an “intellectual capital” program to build an evidence-based case for SRRH. The “subjects” were married and unmarried women and girls ages 10-49, particularly those disadvantaged by income, urban/rural residence, race or ethnicity, and, over time, other characteristics, including sexual orientation and gender identity. The aim was to secure a central place for SRRH in international and national population and public health policy and funding.
The intellectual capital program focused on:
- four interrelated SRH services (contraception, safe abortion, maternity care, STIs) on which IWHC believed significant progress could be made by modifying family planning and MCH policies and programs that already had political support, funding and basic delivery capacity;
- adolescents’ SRRH, including sexuality education and health services; and
- promotion and protection of sexual and reproductive rights (SRR), in their own right and as guiding principles for the other two focus areas.
Strategy for Creating Intellectual Capital
Experiences that Joan Dunlop and I had had in the 1970s and early 1980s working in mainstream institutions indicated that achieving IWHC’s aim would entail an ideological, moral and political struggle, not simply marshaling ideas and evidence. Because it would also require projects and programs to demonstrate the feasibility and efficacy of using the SRRH approach in a range of Southern countries, IWHC, unlike most international feminist health initiatives, made direct engagement with mainstream institutions a core part of our strategy, developing intellectual capital through collaboration with both feminists, especially from the South, who would provide solid information and insights on women’s realities, and also population and public health experts and policy makers who could help generate quantitative evidence, widely credible data analysis, and feasible program and policy recommendations.
Other key elements of the strategy included decisions about the nature of the materials to be created, terminology, primary information sources, authorship and publication.
Nature of the materials
The materials were deliberately designed to tackle several tasks simultaneously:
- building the evidence base on women’s SRRH, drawing on information from women and also on analyses of demographic and public health data using a feminist SRRH lens;
- analyzing the adequacy, and the implications for women’s health and rights, of national and international population and public health policies, funding, data and research frameworks, and the design, implementation and monitoring of services;
- recommending changes that the population and public health sectors could reasonably be expected to make, separately and together; and
- creating evidence-based advocacy tools.
While the timing, content and design of each document IWHC generated were influenced by political context and opportunities for influence, decisions on each document always considered our ultimate goal: a comprehensive web of SRRH information, data and recommendations that would persuade and motivate key actors, including academics and researchers, policy makers, legislators, contraceptive and health service providers, educators and other gatekeepers.
IWHC created and used terminology that reflects women’s health, their agency, and their human rights as persons, not simply as instruments of population control and public health. While this essay uses “SRRH” throughout, IWHC materials used various terms, for editorial and, often, political reasons. For example, “reproductive health”, editorial short hand for SRRH, was often more palatable for governments. Regardless of the particular terms used, IWHC materials always defined and promoted comprehensive SRRH content.
As noted above, IWHC gave central importance to qualitative information from Southern women, in order to illuminate their realities and to compensate for major gaps in quantitative demographic and public health data relevant to SRRH. A second core resource was Southern feminist activists, who began mobilizing in the late 1980s, within and across their professions and their countries, to demand “reproductive rights”. Third, women in mainstream institutions from the mid-1970s onward revealed the extensive sex-based biases in academic disciplines such as demography, women’s inequality in social and economic life, and the likely association of such inequality with poor sexual and reproductive health and avoidable mortality (Presser, 1997). Finally, by the late 1980s and early 1990s, women and men inside a few pivotal population and health institutions such as The Population Council, and professional associations such as the International Federation of Obstetricians and Gynecologists (FIGO), were producing work that validated the concerns of SRRH activists regarding, for example, poor quality of care in family planning programs, and lack of access to safe abortion, respectively. IWHC not only collaborated with these early leaders but also, over the years, motivated and supported many more to work with and independent from IWHC.
Authorship and Publication
IWHC’s intellectual capital program convened meetings, commonly in collaboration with other organizations, to debate and reach consensus on particular SRRH topics. IWHC ensured that the ideas and conclusions of these meetings were written up and disseminated to key audiences. IWHC also commissioned and helped to write papers by population and health experts, policy makers and feminist activists, as a fundamental part of its intellectual contributions to SRRH, and as a key vehicle for engaging the active support of mainstream actors. By the early 1990s, IWHC, with feminist and mainstream colleagues, was publishing peer-reviewed journal articles and book chapters, as well as co-editing books and special issues of influential journals. Simultaneously, IWHC and allies disseminated the content in short forms, especially for advocacy with and through governments, the UN, the press and other media (Corrêa, Germain and Sen, 2015). To the maximum extent possible IWHC arranged for translation, especially of the advocacy materials.
Mobilizing Feminist Advocates and Persuading the Population and Health Fields
Drawing on a wide network of feminists developed during my work at The Ford Foundation from 1972-1985, IWHC identified women across Sub-Saharan Africa, Asia, Latin America and the Caribbean, and the Middle East to join in the intellectual work on SRRH. Most were in their 30’s, had strong academic or professional credentials in a range of fields, were politically active, and, vitally important in the early years, had worked in or had direct experience with mainstream institutions, including their governments. Similarly, our engagement with mainstream population and public health actors built on connections made during my years at The Ford Foundation and drew in allies from two pivotal disciplines, demography and public health epidemiology, and from three globally recognized policy and program areas, family planning, maternal health and HIV and AIDS (Dixon-Mueller and Germain, 2000).
IWHC’s intellectual capital program also collaborated with major donors to population and, later, public health programs, including HIV and AIDS, because they played decisive roles in the policies and program priorities of Southern governments, UN and other international agencies, and academia, among others. The earliest, most extensive relationship was with population donors. IWHC engaged substantively with staff of two of the largest private donors, the Ford and MacArthur Foundations, and four leading government donors, Denmark, the Netherlands, Norway and Sweden, sharing with them the emerging concept of SRRH and its components. As a result of IWHC’s anonymous involvement in pivotal staff appointments at both foundations, our training of European government staff, and our policy and program advice, by the early 1990s, these six population donors began to shift their population policies and funding toward SRRH, and the governments became key champions of SRRH in UN intergovernmental negotiations from 1994 onward (Germain, 2003; Dunlop, 2004). (Examples of IWHC’s significant but less extensive engagement with public health and HIV and AIDS donors are in sections below.)
Defining the “SRRH” Concept
Three subsections describe IWHC’s foundational definition and promotion of SRRH; continuing elaboration of SRRH in collaboration with women’s health and rights activists, primarily from the South, aiming to influence the 1994 UN International Conference on Population and Development (ICPD); and the contributions of IWHC’s intellectual work to protecting and expanding the SRRH concept following the ICPD.
Development of the Initial Concept
The earliest formulations of SRRH were in presentations prepared by IWHC for two 1987 forums, an international conference on family planning, and an annual meeting of international activists, the Association for Women and Development (AWID). The paper for the family planning conference defined the scope of SRRH, using insights from women in the South and available demographic and health data. It challenged family planning and MCH leaders to modify their policies and programs, and to work together under a shared SRRH policy framework, and provided examples of what could be done in countries as diverse as Bangladesh, Brazil, Indonesia and several in Sub-Saharan Africa, drawn from my Ford Foundation work in these countries (Germain, 1987). The AWID conference presentation aimed to persuade leaders of national and international women’s movements to adopt SRRH as a core part of their agenda (International Women’s Health Coalition, 1987). In 1989, IWHC presented these ideas in an advocacy paper, primarily for use with US and European governments that funded population control and MCH programs in the South (Germain and Ordway, 1989).
These early materials defined several premises for international SRRH advocacy and action, which have since been expanded and repeatedly endorsed by feminist activists, including:
- Values: women’s equality and protection of their human rights are necessary for securing their SRRH and for wider social and economic justice;
- Goal: women’s health and human rights are at the center of policies and programs for health, human rights and development in the South;
- Objective: wide access to a minimum package of four services (contraception, maternity care, safe abortion, STD/HIV prevention, diagnosis and treatment), comprehensive sexuality education, and protection of sexual and reproductive rights, especially for disadvantaged groups; and
- Implementation: women must be actors in, not simply subjects of, policies, services and programs; the quality of programs and health services must meet human rights standards, including but not limited to freedom from coercion, violence and discrimination; and nations must be held accountable for enabling women to secure their SRRH.
Elaboration of the SRRH Concept and Mobilizing Support for ICPD
In 1992, delegates to the UN World Conference on the Environment and Development promoted population control and chastised women’s health advocates for demanding better quality, non-coercive family planning services as well as access to safe abortion. In response, several of IWHC’s international colleagues suggested that feminists use the upcoming 1994 UN International Conference on Population and Development, ICPD, to reshape population policy to emphasize women’s health and rights. They asked IWHC to help mobilize a “women’s voice” for ICPD. In September 1992, under the rubric “Women’s Voices 1994,” IWHC convened a diverse group of 24 women from about 18 countries, most in the South, to draft a platform and to decide how to make women’s voices heard throughout the ICPD process. The resulting, ‘Women’s Declaration on Population Policies’ reflected IWHC’s 1987 definition of SRRH (International Women’s Health Coalition, 1993). It set out ‘minimum program requirements’ to support women as whole persons; identified the conditions necessary for women to ‘control their sexuality and their reproductive health’ and to ‘exercise their reproductive rights;’ and defined ‘ethical principles’ to guide population and development policies. Following the meeting, participants circulated the Declaration and, in just six months, secured signatures from over 2,500 individuals and organizations from about 110 countries—testimony to women’s extraordinary networking capacity in the absence of today’s communications technologies.
By early 1993, observing that the official ICPD preparations were not responding to advocacy for SRRH, IWHC and close feminist allies decided to engage a larger, representative group of women activists in preparing a final women’s platform for the ICPD and, in so doing, identify a core group to advocate through the remainder of the ICPD process. As part of IWHC’s strategy for converting mainstream actors to SRRH, IWHC persuaded numerous private and governmental donors to fund a meeting of women’s health and rights advocates in Rio de Janeiro in January 1994, co-organized with CEPIA, a leading Brazilian women’s rights organization and IWHC ally.
Still using only “snail mail”, a highly diverse International Steering Committee selected 215 women (out of 700 nominated by endorsers of the London Declaration) from 79 countries to participate. Their final agreement, “the Rio Statement”, encompassed the content of the London Declaration and expanded on issues such as poverty, development, ‘gender power relationships’, ‘fundamentalisms’ (social and political, not only religious, forms of conservatism), accountability, and the importance of investing in women’s organizations (Reproductive Health and Justice: International Women’s Health Conference for Cairo ’94, 1994). IWHC and allies used the Rio Statement throughout international (UN) and national preparations for the ICPD and during the conference itself.
Simultaneously, IWHC continued work on legitimizing SRRH in influential academic and population institutions. With DAWN (see note 6) and Harvard University, IWHC commissioned 17 essays by authors who spanned a spectrum from prominent international specialists to leading Southern feminists. Meetings of the authors hammered out the content of each chapter so that, together, they would provide a comprehensive statement on the significance of SRRH for population and development policy. The essays addressed population growth, women’s health and human rights, ethics, youth, the work of the women’s health movement, sexual rights, gender and household dynamics, biomedical research, and financing, all topics that IWHC and DAWN thought would–or should–be debated at the ICPD. Sida sponsored the global launch of the book in Zimbabwe and IWHC, DAWN and Harvard promoted it widely in the months leading up to the ICPD. (It has since been used widely in teaching and became a touchstone for new generations of advocates.)
IWHC also secured attention to SRRH in other mainstream publications and forums in preparation for the ICPD and as part of ongoing efforts to legitimize SRRH and the engagement of women in population policymaking and implementation. For instance, the first of several articles on women’s engagement in political action on population and public health policy drew on IWHC-supported work by local colleagues in Brazil, Nigeria and the Philippines (Dixon-Mueller and Germain, 1994). Published in a special issue of the leading international population policy journal, the article aimed to demonstrate to the population field the benefits of including feminist activists in population policy processes. Comments on the draft of the paper, by the issue’s editors and by authors of the other papers, typified population establishment hostility to SRRH and to meaningful inclusion of feminists in their domain (Dixon-Mueller, 1990). In addition to this article, a shortened version of IWHC’s 1989 advocacy paper was included in a book published by an environmental press during the lead up to the ICPD (Mazur, 1994). Though this book was funded by population donors, the editor included an entire section on ‘Population Policy, Reproductive Health and Reproductive Rights,’ with seven chapters by nine authors of diverse backgrounds. This is an example of early progress toward accommodation of SRRH in the “population” agenda before the ICPD.
The ICPD outcome, a “Programme of Action” agreed by 179 governments, represented what most acknowledge as a “paradigm shift” in population policy, which placed the sexual and reproductive health and reproductive rights (SRH + RR) of women and adolescents, as well as their equality and empowerment, at the center (United Nations, 1995).
The Programme includes almost all the elements of the women’s platform for ICPD, including expansive definitions of reproductive and sexual health and reproductive rights, the supply side of SRRH (provision of good quality, comprehensive SRH services including safe abortion where not against the law) and also the demand side (socio-economic conditions and human rights protections that enable women and girls to access and effectively use SRH information and services). The Programme of Action encompasses issues never before addressed by the population and family planning field, including sexuality and sex education, adolescents’ right to SRH services, violence against women, STIs, infertility and reproductive cancers.
Promotion of SRRH Following the ICPD
Many in the population and family planning community opposed the ICPD Programme of Action, echoing earlier opposition, in the 1970s and 1980s, to a women’s rights perspective on population policy (Presser, 1997; Germain, 1997). Others who accepted the Programme did not fully understand what SRRH encompasses and how to implement it (Dixon-Mueller and Germain, 2015). IWHC therefore published an analysis of the Programme of Action and its significance, and, with allies, helped create country-level opportunities to implement the ICPD Programme through the kinds of action suggested in the 1987 family planning conference paper (Germain and Kyte, 1995).
IWHC invested particularly deeply in Bangladesh, building on my Ford Foundation experience there from 1975-85, as well as on IWHC-supported programs from 1985 onward. The Bangladesh government had played a significant role in the ICPD and, afterwards, decided to transform their widely recognized national family planning program into a ‘health and population’ program using the SRRH approach. Sida, a major donor to the national family planning program, asked IWHC to work with them to ensure that the design of the new program would, at a minimum, expand access to early abortion services; develop skilled obstetric care capacity nationwide; mandate the first national STD and HIV prevention initiative; improve the quality of care, especially in family planning services; and test ways to reach young married couples. IWHC agreed with these priorities and committed to engaging Bangladesh civil society, especially women, throughout the design process as central stakeholders.
Framing and financing what became the national ‘health, nutrition and population program’ took three years of negotiation with all stakeholders, including the government and donors, the most powerful of whom opposed the SRRH approach. IWHC ensured that the work was documented and its achievements published as inspiration for action in other countries (Jahan, 2003, 2007; Jahan and Germain, 2004). After five years of program implementation, maternal mortality, among the highest in the South, had dropped 25 % and infant mortality 22 %. By 2008, maternal mortality was down by 40%, and Bangladesh is one of the few high burden countries to achieve the UN Millennium Development Goal on maternal mortality reduction (see below). Contrary to some pessimistic forecasts, contraceptive prevalence, already high compared to other high fertility countries, remained so under the new program approach.
The Bangladesh initiative was one of the earliest and most significant national efforts to implement the ICPD SRRH agenda. It demonstrated that the SRRH approach is feasible at national scale even in resource-limited countries, that it is highly beneficial to women and families, and that it enhances, rather than undermines, reduction of population growth. It also demonstrated the kinds of political action needed to secure policy change and implementation.
After the ICPD, IWHC also published many advocacy tools for country-based advocates, and for those working to protect SRRH in UN intergovernmental negotiations. One of the more elaborate of these initiatives was led by HERA (Health, Empowerment, Rights and Accountability), an informal subgroup of IWHC’s ICPD allies. Facilitated by IWHC as the Secretariat, HERA created a set of advocacy “action sheets”, which provided definitions and evidence on reproductive rights and reproductive health, sexual rights, sexual health, adolescents’ sexual rights and health, abortion, men’s role and responsibility, gender equality and equity, women’s empowerment, and advocacy (HERA Secretariat and International Women’s Health Coalition, 1996). Like other IWHC collaborations, HERA’s work deepened and expanded the original 1987 SRRH concept and recommendations for action. IWHC and HERA effectively used their work in the 1995 UN Fourth World Conference on Women (“Beijing Conference”), to ensure that the Conference reaffirmed the ICPD SRRH commitments, and expanded several, including those on abortion, adolescents’ SRRH, and men’s role. Most remarkably, although the Beijing Conference Platform for Action did not use the term “sexual rights,” it elaborated the content for the first time in a UN agreement (Dunlop, Kyte and Macdonald, 1996; United Nations, 1996).
In the decades following HERA’s work, IWHC facilitated the creation of many more fact-based SRRH advocacy tools for burgeoning UN intergovernmental negotiations on or related to SRRH. In the 1990s, these negotiations were primarily UN-mandated reviews of national, regional and global implementation of the ICPD and Beijing Conference commitments, and of UN agreements on ending HIV and AIDS (Girard, 1999). Beginning in 2001, the negotiation and follow up of the UN Millennium Development Goals (MDGs, 2000-2015), and creation of the successor Sustainable Development Goals (SDGs, 2016-30), added opportunities for, and also challenges to, the promotion and protection of governments’ SRRH commitments.
In addition to meeting the direct demands of UN negotiations, IWHC’s intellectual capital program reached out to population and health professionals working on framing and monitoring the global development goals and their national implementation (Germain and Dixon-Mueller, 2005; Sen et al., 2015). IWHC also sought to influence policy debates on strengthening health systems, on universal health coverage, and new health initiatives for low income countries such as the International Health Partnership +. Materials argued that enabling country health systems to provide SRH services would be a strong foundation for strengthening health systems overall, promoted an integrated package of SRH services and emphasized accountability (Germain, 2011; International Women’s Health Coalition, 2012, 2009b). These were complemented by continuing work on US foreign policy, including in preparation for a new U.S. Administration in 2009 (Germain, 2008a). Finally, IWHC both published ideas for the future of the SRRH movement and promoted respect for and involvement of the movement in policy processes (Corrêa, Germain and Petchesky, 2005; Germain and Liljestrand, 2009; Germain, 2010).
Elaborating Selected SRRH Elements
This section reviews IWHC’s intellectual contributions on three central components of SRRH: birth control (abortion and contraception), sexually transmitted infections (STIs) and HIV, and adolescents’ SRRH. Work on these topics involved collaboration with both feminists and specialized researchers and technical experts; meetings and publications by IWHC, articles in peer reviewed journals and books, and advocacy tools. Simultaneously, IWHC provided considerable intellectual input to staff of WHO and, to a lesser extent, UNAIDS, UNFPA and the World Bank, for their program strategies, papers for their governing boards, draft intergovernmental resolutions, program assessments and evaluations.
Birth Control (abortion and contraception)
IWHC’s substantive work on abortion began at the 1985 UN Third World Women’s Conference in Nairobi, when IWHC mobilized allies to thwart abortion opponents’ “right to life” (anti-abortion) polemic by asserting a women’s definition of “right to life” that includes women’s right to protect their own health and lives, to control their bodies and to have only the children they want and can provide for. From 1985 on, IWHC staff met countless women who had had unsafe abortions, financed abortion services in strategically selected countries with diverse abortion laws, and supported local advocacy for legal, regulatory and policy change in many more countries.
IWHC-supported service providers worked within local legal, health system and resource constraints in order to demonstrate practical approaches suitable for scaling up by governments, and to provide evidence for advocacy in these and other countries. The services demonstrated and helped legitimize use of inexpensive manual vacuum aspiration (MVA) technology, well suited for but not yet widely known in resource-constrained Southern countries; provision of contraception, and STI diagnosis and treatment, with abortion care; and other low cost improvements in service quality (informed and free consent, privacy and confidentiality, cleanliness, staff attitudes toward clients especially adolescents and unmarried women, record systems and follow-up, among others) (Reproductive Health Technologies Project, 2016). IWHC-commissioned evaluations concluded that MVA could be provided safely and at low cost by specifically trained mid-level providers, not only physicians, a major requirement for service expansion in countries with weak health system capacity. They also noted the importance of service quality and of outreach to women, especially young women, who generally lacked vital information about pregnancy and the social support necessary to use SRH services (Dixon-Mueller, 1988
In 1987 in Brazil, IWHC convened the second Christopher Tietze International Symposium following the triennial meeting of the International Federation of Gynecology and Obstetrics (FIGO), in which over 200 FIGO members and others debated global and national actions to reduce high levels of morbidity and mortality from unsafe abortion. The Symposium papers, grounded in country experiences including IWHC-supported programs, were written by leading physicians, experts on law and ethics, service providers and policy makers, many of whom had not previously used an SRRH perspective (Rosenfield et al., 1989). Characteristically, IWHC’s invitations to write papers, collaboration with authors during drafting and the Symposium itself all helped introduce authors and participants to new ways of thinking about women’s health and human rights.
Over the years, to face down international anti-abortion activism, activate passive supporters, and create a foundation for advocacy in both national and UN forums, IWHC continuously developed and refined a multi-faceted, data-based case for access to safe abortion services. These publications provided evidence that abortion is a commonly used method of birth control and is exceptionally safe when properly provided by trained providers in hygienic conditions; argued that access to safe abortion is essential for reducing maternal mortality and morbidity and to prevent poor health and death among children whose mothers die or are incapacitated by unsafe abortion; and asserted that access to safe abortion is fundamental right, fulfillment of which is essential for women’s empowerment and realization of their other human rights (Dixon-Mueller and Germain, 1993; International Women’s Health Coalition, 2009a).,
Perhaps most significant, IWHC pioneered a new perspective for abortion rights advocacy. Most advocates referred to abortion as “illegal” and prioritized removal or softening of legal restrictions as a pre-condition for expanding access. Knowing that legal change could take many years during which hundreds of thousands of women would die or be seriously injured, IWHC promoted investment in safe abortion services for all women “eligible under existing laws”. The rationale was that laws in almost all countries allow abortion to save the life of the woman and on at least one or more additional grounds, such as protecting the woman’s health, in cases of rape or incest, or when severe fetal anomalies exist. Using this perspective, IWHC argued that all countries, except the four or five that disallow abortion on any grounds, are obligated to train and equip health care providers and facilities to provide safe abortion and treatment for the complications of unsafe abortion.
IWHC published a paper and other advocacy materials promoting this position for the 1999 UN review of ICPD implementation. The outcome document of this negotiation greatly enhanced the ICPD agreement (abortion must be safe where not against the law) by saying that health care providers should be trained and equipped to serve women eligible under law (Germain and Kim, 1998; United Nations General Assembly, 1999). Knowing the reliance of Southern country governments on health norms and standards set by WHO, IWHC then persuaded WHO to produce technical and policy guidance for countries on access to safe abortion, based on the affirmative premise that abortion is “legal” in all but four or five countries on one or more grounds (World Health Organization, 2003, 2012). WHO agreed to refer to abortion as “legal” or “legally restricted,” rather than “illegal,” and to address not only clinical matters but also policy, legal, regulatory and other barriers to access, the latter unprecedented in WHO guidelines. IWHC played a major role in drafting the guidance and securing inputs from legal, policy and other experts as well as feminist advocates. Many of the recommendations and concrete examples in the WHO guidance came from the country-based service provision and advocacy for legal, policy and regulatory reforms supported by IWHC.
IWHC also promoted MVA widely, through publications as well as direct advocacy, in countries as disparate as Turkey, Nigeria and Brazil, pointing out that MVA is much safer and easier than the conventional dilation and curettage “D and C”) and has other advantages, especially in low resource countries. After the safety and efficacy of medication abortion had been demonstrated and recognized by WHO and the US FDA, IWHC also supported medication abortion to expand the range of choices available to women in diverse circumstances. In 2009, based on requests from colleagues particularly in Latin America, IWHC, together with Gynuity, a US NGO deeply versed in research and clinical practice, produced and widely disseminated guidance on using self-administered misoprostol for abortion (International Women’s Health Coalition and Gynuity Health Projects, 2010).
IWHC’s intellectual capital work on improving the quality of contraceptive services, like the abortion work, faced significant political challenges. Many conservatives including abortion opponents opposed contraception. Others recognized contraception as a way to reduce the need for abortion, or as the means to population control, but did not embrace the quality of care agenda. IWHC’s intellectual capital program generated dialogue and collaboration among women’s advocates, contraceptive researchers, demographers and family planning leaders, to garner support for three interrelated actions: including women’s health advocates in contraceptive research and development processes; revising the premises of demographic research and training, and the assumptions underlying population policy and family planning programs; and third, influencing the design and monitoring of family planning services.
In 1990, based partly on relationships forged for the 1989 Tietze Symposium described above, the director of WHO’s Special Programme of Research on Human Reproduction (HRP) invited IWHC to recommend how HRP could effectively solicit and respond to women’s perspectives. Following extensive consultations with HRP’s staff, IWHC proposed that IWHC and WHO co-convene a meeting between HRP’s worldwide contraceptive researchers and women’s health advocates to determine where they agreed, and where they could agree to disagree and continue work toward consensus. Every aspect of the meeting’s design and process involved equal leadership and participation by women’s health advocates and contraceptive specialists. To inspire more such dialogue, the meeting report describes both how the conversation identified common ground and also its outcomes (WHO Special Programme of Research, Development and Research Training in Human Reproduction and International Women’s Health Coalition, 1991).
Much additional substantive work, including several publications by WHO’s headquarters and regional staff with women’s health advocates, flowed from this landmark meeting (Germain and Faundes, 1994). One notable global effort was an international symposium convened by HRP and the Government of Mexico in preparation for the ICPD (Marcelo and Germain, 1994). The Symposium Declaration reflects the emerging willingness of scientists to include women’s views on SRRH research, policies and programs (Van Look and Pérez-Palacios, 1994).
Also as a direct result of the “common ground” meeting, HRP and WHO’s Department of Reproductive Health and Research (RHR) made significant staffing and program changes, with sustained IWHC collaboration. HRP appointed an experienced feminist health advocate, first as a consultant and then as staff. She was instrumental in modifying HRP’s contraceptive research agenda; including qualified women’s health advocates in technical advisory committees, expert groups and the review processes for proposals and publications; adding social science research to HRP’s biomedical and clinical research programs; recruiting expert staff for new work on human rights, including sexual health and rights; and creating a Gender Advisory Panel (GAP) for HRP and RHR (Cottingham, 2015).
The second area of IWHC’s contraception-related substantive work challenged several underlying premises of population policies and family planning programs. Using a women’s health and rights perspective, these materials:
- Critiqued the population sector’s premise that the relatively higher risk of pregnancy compared to the risks of contraceptive use and pregnancy justifies giving priority to contraceptive services over maternity care where resources are limited (Dixon-Mueller and Germain, 1993);
- Proposed revising the definition of “unmet need for family planning,” a fundamental policy and planning tool used in population programs, to include the unmarried, those dissatisfied with their contraceptive method, and those who had discontinued contraceptive use for remediable reasons such as poor quality services, and fear of or experience with side effects that could be prevented or managed (Dixon-Mueller and Germain, 1992, 1993);
- Analyzed shortcomings in family planning program indicators, which emphasized the supply side (numbers of new “acceptors”, contraceptive prevalence rate, and “couple years of protection”, a theoretical estimate that has no relationship to actual couples’ behavior) to the exclusion of the demand side (women’s knowledge of and experience with services) (Dixon-Mueller and Germain, 2007a); and
- Argued for attention to the key role of sexual behavior, which the population sector assiduously avoided (Dixon-Mueller, 1993).
In ensuing years, policy analysts and researchers gradually took up many of these concerns, as reflected in the meeting agendas of leading professional groups, such as the Population Association of America and the IUSSP, and in the research agendas of institutions such as The Population Council.
These ideas had profound implications for the third area of IWHC’s contraception-related work, improving the accessibility and quality of services. IWHC’s and allies’ advocacy produced the global ICPD agreements that “unmet need” should encompass more people than “married women of reproductive age (15-49)”; that demographic targets, and incentives for providers and “acceptors” of contraceptives, should be ended and additional measures be taken to ensure fully informed and free consent to contraception; and that improving the technical quality of services and treating clients with respect are high priority; among others. Nonetheless, and despite IWHC’s and allies’ continuing substantive work and advocacy, governments and the largest, most influential donors did little (Germain, 2013).
Sexually Transmitted Infections, HIV and AIDS
IWHC’s work to reduce women’s and girls’ vulnerability to reproductive tract infections (RTIs), including sexually transmitted infections (STIs), HIV and others began in 1987, in response to women’s expressed concern about the health and social consequences of symptoms such as vaginal discharge and pain. Because almost no epidemiological data or services existed on STIs among women in the general population in the South, IWHC’s intellectual capital program decided to define the problem and the actions needed, derived in part from research on STI prevalence and prevention interventions in Indonesia for which IWHC provided funding and consultant expertise.
In 1991, IWHC designed and convened a meeting of high-level academic researchers, UN and government experts, and women’s health advocates, to make the initial case and recommendations for integrating STI prevention, diagnosis and treatment into public health and family planning programs in the South. Following publication of the meeting report and a landmark position paper for advocacy, IWHC invited papers from leading scientists, STD/HIV clinicians and family planning/maternal and child health practitioners, a social scientist and national experts from Brazil, Kenya, India, Nigeria and Mozambique, to assess current research and policies, and propose strategies and actions to reduce women’s vulnerability to STIs and HIV (Dixon-Mueller and Wasserheit, 1991; Germain, 1991; Germain et al., 1992).
Though significant, these papers, which focused on disease control and pregnancy prevention at the societal rather than individual level, did not fully address the determinants of women’s vulnerability to infections and, consequently, the recommendations were incomplete. IWHC and the Women and Development Unit, University of the West Indies, therefore convened 44 feminists from 22 countries in Barbados in 1992 to fill these gaps. Participants reviewed the many factors (poverty, violence, promiscuous partners, unequal gender power) that make women vulnerable to STIs and HIV. Recognizing the limitations of condoms, participants called for creation of one or more women-controlled STI prevention technologies and identified the characteristics such methods should have. They named these potential methods “microbicides,” asked IWHC and WAND to disseminate a report of the meeting, and urged IWHC to find and support researchers that could create such methods (Antrobus, Germain and Nowrojee, 1994).
IWHC identified an exceptional biomedical scientist at The Population Council, then a leading contraceptive R and D institution; raised funds to hasten his work; and helped persuade The Council to undertake an unprecedented collaboration with a feminist advocacy group.  IWHC created Women’s Health Advocates on Microbicides (WHAM), whose members represented communities of sex workers in Asia and highly vulnerable women in Sub-Saharan Africa, among others.
With secretariat support from IWHC, WHAM members, met repeatedly with The Council’s researchers and program leaders to identify which of the method characteristics identified in the Barbados could and should be pursued; develop research and ethical standards to protect the human rights of women during clinical trials, which, for technical reasons, would be conducted among women highly vulnerable to STIs and HIV, such as those represented in WHAM; create processes for including women’s health advocates in data analysis; and share findings early and often with the women and communities participating in the research. As interest in microbicides grew, IWHC, WHAM and The Council encouraged other biomedical researchers to engage with representatives of women, including by convening an unprecedented symposium of researchers and women’s health advocates (Heise, McGrory and Wood, 1998).
While IWHC pursued these initiatives, global policy, funding and institutions for HIV and AIDS mushroomed—without attention to girls and women in the general population, despite evidence of their disproportionate vulnerability. One factor in this neglect was the central principle of communicable disease, namely that priority be given to the groups who are most likely to transmit infection—for HIV these are men who have sex with men, IV drug users, and sex workers and their clients. IWHC and allies, especially women living with HIV and AIDS, therefore decided to pursue an HIV and AIDS policy paradigm shift, analogous to the 1994 population policy shift.
As for population policy, the strategy included challenging the assumptions of a lead discipline, in this case epidemiology, and gaining a voice for Southern women among the primarily Western HIV and AIDS policy makers and activists, based on two premises. First, protecting the sexual and reproductive rights and health of women and girls in the general population is necessary to end HIV and AIDS. Second, integrating HIV and AIDS services into other sexual and reproductive health services would best serve women. Like the population sector, the HIV and AIDS sector disagreed with the first, and felt the second threatened the sector’s autonomy and resources.
Nonetheless, feminists, including women living with HIV and AIDS, persistently promoted actions to address the determinants of girls’ and women’s vulnerability and to provide services to women in the general population; protections for women’s rights in intergovernmental agreements on HIV and AIDS; and modifications of global HIV and AIDs institutions, policies and funding to encompass women’s SRRH. IWHC’s intellectual capital program made the case for addressing HIV and AIDS as part of a broad SRRH agenda for girls and women, rather than as a separate vertical program, and countered simplistic assertions that HIV and AIDS have priority over other causes of premature death and disability in women (Germain, 2009; Germain, Dixon-Mueller and Sen, 2009; Germain and Dixon-Mueller, 2010). IWHC also promoted greater emphasis, controversial in some quarters, on supporting individuals to inform their partners of their HIV and AIDS status (Dixon-Mueller, 2007; Dixon-Mueller and Germain, 2007b; Sanon et al., 2009). As incontrovertible data emerged on the extent of infection among girls and young women, and especially on vertical transmission through pregnancy and child birth, some progress occurred in global policy and program rhetoric on women (Joint United Nations Programme on HIV/AIDS, 2010, 2015). But funds and concrete actions fell far short of the need, including from the largest and most powerful global HIV and AIDS donor, the US government’s PEPFAR program (International Women’s Health Coalition, 2008c; 2008d).
The HIV and AIDS sector, unlike the population sector, was open to work on two fundamental aspects of SRRH—sexuality and adolescents’ health and human rights. Early HIV and AIDS research, policies, and program norms encompassed sexuality and sexual rights, creating opportunities for SRRH activists’ work. For instance, at the turn of the 21st century, a WHO expert group, including IWHC staff, produced a definition of sexual health and rights, which reflects IWHC’s intellectual work since 1987, that is posted on WHO’s website, with the standard caveat that it is not an official WHO position (World Health Organization, 2016a). Concerned that HIV institutions and advocates were emphasizing protection of individuals’ rights without explicit attention to their responsibilities, IWHC’s intellectual capital program also proposed an ethical framework for sexual partnerships suitable for adoption by SRRH policies and programs, including those concerned with HIV and AIDS (Dixon-Mueller et al., 2009)
The second pivotal area of work that HIV and AIDS helped legitimize was adolescents’ SRRH.
Adolescents’ sexual and reproductive rights and health
IWHC called attention to the health and human rights of adolescent girls in the 1987-89 conference presentations referenced above, stressing the need for information and education on sexuality, gender roles and power relationships; access to SRRH services; and protection of their sexual and reproductive rights. At the time (and today), harmful practices such as early and forced marriage, FGM, crimes in the name of honor, sexual violence and trafficking, among others, were widespread but not yet well documented. Sex education did not exist in most Southern countries and adolescents were excluded from health services by law or by the attitudes and practices of health care providers, families and community leaders. Adolescents were generally considered subject to parental control, with no agency and limited rights, especially in the arenas of sexuality, marriage and child bearing.
In the early 1990s, IWHC’s colleagues, especially in Brazil, Cameroun, Indonesia and Nigeria, asked IWHC to support programs with and for adolescents, especially girls. Their vision encompassed girls’ self-esteem and their agency as actors in their own lives as well as comprehensive sexuality education for all. IWHC staff and expert consultants assisted colleagues to develop curricula that included both information and development of skills adolescents need for decision making, relationships, and accessing health and other services. Equally important, IWHC assisted colleagues to design training for sex education facilitators that encouraged nonjudgmental attitudes, respect for adolescents’ agency and provision of full and accurate information. IWHC’s intellectual capital program drew on lessons from these initiatives to formulate policy and program recommendations for the ICPD, using both public health and human rights arguments.  Adolescents’ SRRH, including their right to sex education and to access SRH services, were addressed in some 42 paragraphs of the ICPD Programme of Action. Following the ICPD, HERA produced an action sheet on “Adolescents’ Sexual Rights and Health,” and worked successfully to protect and expand the ICPD agreements on adolescents in the Platform for Action produced by the Beijing Conference (HERA Secretariat and International Women’s Health Coalition, 1996; United Nations, 1996).
Drawing on country programs, IWHC published evidence-based lesson plans, and guidance on program design and provider training, that could be locally adapted by policy makers, educators and others across the South (Irvin, 2004). This publication, like the country programs, addressed both standard topics of puberty, contraception and HIV prevention, and also rarely-addressed issues such as romantic relationships, sexual behavior, sexual rights, STIs, sexual orientation, abortion, violence and harmful practices that HERA had laid out in the mid-1990s. The program guidance addressed key actions such as securing community and parental support, developing respectful and nonjudgmental attitudes among providers of sex education, and responding effectively to children’s and adolescents’ questions, among others.
After this publication, the lead UN agency for education, UNESCO, produced technical guidance on sexuality education that addressed many though not all of the same issues, and IWHC collaborated with The Population Council and others on an even more progressive “sexuality and gender” education curriculum (Dixon-Mueller, 2010; International Sexuality and HIV Curriculum Working Group, 2011a; 2011b; International Women’s Health Coalition, 2011). IWHC produced many more advocacy tools based on these publications for use in UN intergovernmental negotiations that repeatedly (though not easily) reaffirmed commitments to sex education (International Women’s Health Coalition, 2007a; 2007b; 2007c; 2007d; 2007e; 2007f; 2008a; 2008b; Dixon-Mueller, 2008).
The SRRH paradigm demands fundamental changes in a basic building block of human society—the relative status and power held by women compared to men, from intimate relationships to the highest levels of public power. It requires supportive actions by dominant population and health institutions and professionals still determined to protect their separate domains, resources and ideas. After three decades of work to change the positions of the health and population sectors, is the SRRH glass half full or half empty? Given the rock-bottom base from which SRRH work started, the glass is at least half full—an especially impressive accomplishment in light of persistent political and other opposition, and worldwide retreat from the liberal, democratic values that underlie SRRH.
Quantifiable progress toward SRRH since the ICPD, driven by an increasingly skilled feminist political movement and by countries’ desire to achieve their global commitments, is evident in global SRH indicators, such as maternal mortality, contraceptive prevalence rate, and adolescent pregnancy rates (United Nations, 2015, pg. 38-43). Less measurable, but no less significant, progress has been made toward women’s and adolescents’ SRRH in the rhetoric, and in many cases, the policies, programs, budgets and staffing of influential health and population institutions, professional associations and journals. Major innovations have occurred in birth control, including emergency contraception and medication for safe abortion, and both WHO and FIGO have endorsed training a variety of health workers to provide safe abortion (World Health Organization, 2015a).
Female condoms now exist for dual protection against pregnancy and STIs including HIV, and microbicides research, facilitated by an unprecedented international partnership established in response to IWHC’s and WHAM’s early work, may be on the verge of producing the first woman-controlled protective method (International Partnership For Microbicides, 2016). WHO has created methodologies to track not only maternal mortality but also maternal morbidity, the latter a huge portion of the maternal health challenge unmonitored until now (Chou et al., 2016). Significant work has been done on the content and quality of comprehensive sexuality education, access and efficacy (United Nations Educational, Scientific and Cultural Organization, 2015). Academics have developed standards for gender analysis in public health research (Morgan et al., 2016).
Thanks to strenuous efforts by SRRH supporters inside and outside the UN, major global actions for SRRH have been initiated, notably the 2011 campaign, “Every Woman Every Child,” which addresses maternal mortality reduction, the poorest performing MDG. The 2016 Global Strategy to move this initiative faster highlights adolescents’ SRRH, and a global financing facility for women’s, children’s and adolescents’ health has been approved (Every Woman Every Child, 2015). In May 2016, based on two decades of exceptional WHO work, the World Health Assembly adopted a global plan of action to address violence against women and girls (World Health Organization, 2016b). Numerous governments in the South have expanded programs and modified policies, laws and regulations, and have taken other measures to make various SRH services more accessible and to protect SRR. For example, on abortion, progressive revisions in national laws and regulations outnumber regressive ones; and major campaigns have been mounted by governments, not only activists, such as the 2016 continental campaign for decriminalization of abortion by the African Commission on Human and Peoples’ Rights (Asuagbor, 2016).
Perusal of official documents on the website of the Office of the UN High Commissioner on Human Rights suggests remarkable progress on SRRH by pivotal UN human rights bodies—based on path breaking reports and recommendations, most recently on sex, gender and sexuality, and adolescents’ SRRH by UN Special Rapporteurs on health and on torture, among others (Office of the High Commissioner of Human Rights, 2016b; United Nations Human Rights Council, 2016a; 2016b). Periodic reviews of countries’ human rights records by the UN Human Rights Council have held some governments accountable for sexual rights violations and urged states to decriminalize abortion, provide sexuality education, protect reproductive rights, end violence and discrimination based on sexual orientation and gender identity, and decriminalize sex work, among others (International Planned Parenthood Federation and Sexual Rights Initiative, 2012). In 2016, the UN’s Committee on Economic, Social and Cultural Rights issued its first official statement that the right to sexual and reproductive health encompasses a right to the full range of SRH services including abortion, comprehensive sexuality education, and quality, and the Commission on the Rights of the Child as of October 2016, is considering a new resolution strengthening its 2013 statement (General Comment 15) on adolescents’ SRRH, including safe abortion access and mandatory comprehensive sexuality education (Committee on the Rights of the Child, 2013; Committee on Economic, Social and Cultural Rights, 2016).
Despite such progress toward the SRRH vision, the SRRH glass can seem half empty. An estimated 303,000 women still die each year in pregnancy and childbirth, almost all of them from preventable causes in Southern countries. At least 225 million women in the South have an unmet need for family planning. High abortion rates continue and most abortions in the South are still unsafe even where laws are liberal (Horton, 2016; Sedgh et al., 2016). About 270,000 women die annually of cervical cancer, reflecting continuing failure to prevent sexually transmitted diseases. And a staggering 1 in 3 women 15-49 years old experience physical and or sexual violence either within or outside the home (Every Woman Every Child, 2015). Globally, women and girls are still the most affected by the AIDS epidemic (Joint United Nations Programme on HIV/AIDS, 2015; Office of the High Commissioner of Human Rights, 2016a). Inequities abound: Countries in Sub-Saharan Africa and South Asia, and lower income and rural women and adolescents across the South, continue to bear by far the largest burdens of poor SRRH.
Many factors are responsible, including weak, underfunded health systems, widespread failure to address the socio-economic determinants of SRRH, and political as well as social opposition to legal and policy changes for women’s health and human rights. Of particular concern, given the imperative need to use limited resources in the most effective way, are large global investments that purport to advance SRRH, but instead can inhibit progress. Examples such as the following are particularly egregious given the known benefits of SRRH investments for women, their families and nations, including health systems (Anderson et al., 2016).
The first example is ‘Family Planning 2020,’ a multi-partner initiative, which includes all major population institutions, including UNFPA and WHO, donors, governments and large NGOs such as the International Planned Parenthood Federation (Family Planning 2020, 2016). Launched in 2012, FP2020 dominates policy and funding for contraceptive services in Southern countries. It employs SRRH rhetoric, and could have significantly advanced SRRH. Instead, FP2020 adopted the pre-ICPD approach to family planning—vertical contraceptive services; promotion of long acting reversible contraceptives (LARCs) without commensurate emphasis on their removal or on real choice among other methods; and prioritization of new “acceptors” over current users, many of whom are dissatisfied and, research shows, likely to discontinue because of side effects and poor quality care (Cottingham, Germain and Hunt, 2012; Germain, 2015). A recent typical example of FP2020 partners’ work that runs counter to SRRH principles is WHO guidance for family planning counselling, which is described as ‘rights-based’ but encourages primacy for LARCs, contravening the right to fully informed and free choice among methods (Stanback et al., 2015).
A second large global investment that has unnecessarily inhibited SRRH progress is the US government’s global program, President’s Emergency Plan for AIDS Relief (PEPFAR). This program still invests in abstinence-only programs, despite clear evidence that these do not work and can do harm (Richter, 2016). It further has had dominant influence on the design and programming of the two largest global HIV and AIDS institutions, UNAIDS and The Global Fund to Fight AIDS, Tuberculosis and Malaria, which have steadfastly avoided the SRRH approach and have yet to seriously address the health and rights of women in the general population who are highly vulnerable to HIV and AIDS.
Technologies exist, effective program designs have been demonstrated, and the estimated cost of delivering SRH in the South, about $39 billion annually, is within reach (Singh, Darroch and Ashford, 2014). Nonetheless, funding falls far short, for the health sector overall and for SRRH initiatives such as the Global Financial Facility for women’s, children’s and adolescents’ health (Anderson et al., 2016). Wide, not to say universal, implementation of the remarkable intergovernmental agreements on SRRH requires continuing, even increased, efforts to generate political will in the face of narrow sectoral interests and persistent ideological opposition. As recently as 2011, several factors seemed to bode well for SRRH implementation, but SRRH activists and friends inside the mainstream currently face resurgent opposition (Shetty, 2011; Cumberland, 2012).
Feminists and allies secured the moral high ground at the ICPD by giving voice and political weight to women and adolescents, not as instruments to the ends of population control and public health, but as primary constituents with the most at stake. The ideas, the evidence base, the program experiences and the political movement that IWHC and allies initiated, along with their sustained constructive engagement with governments, the UN, donors, and the population and health sectors provide a solid foundation for the work ahead. The SRRH movement now has the skills, the larger numbers, including younger generations and mainstream allies, and the resilience required to recover from setbacks and to continuously reinvent itself in response to progress.
Feminist women activists, from all countries and walks of life, have brought SRRH very far—farther than most dared to dream in the 1980s. They are the ones most likely to inspire and persistently push everyone else along the steep road to SRRH—protecting the agreements, generating political will for funding and implementation, and holding governments and others accountable for progress (Corrêa, Germain and Sen, 2015; Germain et al., 2015; Sen et al., 2015).
 By the mid-1980s, “South”, rather than “Third World” or “developing,” was the moniker used by progressives for countries of Africa, Asia, Latin America and the Middle East. This essay should be read in conjunction with references below, also in the Smith Collection. The first three provide additional information on the context in which IWHC’s intellectual work was developed, and on the collaborative work that Joan Dunlop and I did, beginning in 1973, to promote a fundamental shift in international population policies and funding (Germain, 2003; Dunlop, 2004; Rossano and Johnson, 2015). The fourth reference analyses the global political strategies and actions that IWHC and its allies used to promote SRRH from 1992 forward (Corrêa, Germain and Sen, 2015). A piece written for a Feminist Press book provides a historical and situational perspective on the need for multi-sectoral action (Germain, 1989).
 IWHC’s primary program was grants to and professional collaboration with local, primarily women-led organizations in 10-12 strategically chosen countries of the South. These investments were beneficial in themselves and IWHC also drew on them and their leaders for its intellectual work. The country and intellectual capital programs were buttressed by communications and policy advocacy programs.
 International and national women’s health and rights advocates also promoted the SRRH of women with disabilities, older women and others that IWHC did not address. IWHC staff published a significant, early paper on the reproductive rights of refugees and internally displaced persons (Girard and Waldman, 2000).
 Other SRH services, such as those for reproductive cancers or infertility were hardly recognized and had no political support or funding in most Southern countries. IWHC staff published a paper on women’s mental health (Gülçür, 2000).
 By contrast, many use various SRRH terms selectively. Those who prioritize population control and family planning use “family planning and reproductive health”, which appears to support SRH but in fact highlights contraceptive services compared to other core elements of SRRH. Opponents of SRRH, aiming to discredit the concept, incorrectly assert, for example, that “reproductive health” is a euphemism for abortion on demand. The current President of IWHC has analyzed language examples from intergovernmental negotiations (Girard, 2009).
 Documented by DAWN (Development Alternatives with Women for a New Era), a “network of Southern women activists and researchers concerned with the impact of development models on gender systems,” that flourishes today (Corrêa, 1994).
 I conceptualized most meetings, and authored, co-authored or co-edited the published materials, many with two IWHC consultants, Ruth Dixon-Mueller, a demographer, and Judith Wasserheit, an STI and HIV expert.
 IWHC’s direct use of the published materials through its “policy advocacy” and “communications” programs are not documented here.
 Many of these, and also colleagues from the mainstream, are named in the remarks I made when receiving the 2012 United Nations Population Award (Germain, 2012).
 These donors provided invaluable, highly unusual multi-year general support grants to IWHC for decades, giving IWHC the autonomy and flexibility to undertake innovative intellectual work, to create and take advantage of opportunities for influence, and to advocate for SRRH with the full engagement of our Southern feminist colleagues. Over the decades, as more donors began to understand SRRH, IWHC also gained many other institutional supporters, including US and European foundations, the governments of the UK, Switzerland, Germany, Canada and Australia, and UN agencies including UNFPA, the World Bank and WHO. IWHC worked to influence the US government’s foreign assistance agency, USAID, by far the largest donor to family planning, but did not seek or accept USAID funding because of their promotion of population control and the kinds of conditions they impose on recipients.
 Mahmoud F. Fathalla, then at WHO, a FIGO leader, and an important colleague of IWHC from 1990 forward, independently published a very similar concept in 1988 (Fathalla, 1988; Germain, 2008b).
 IWHC also reached out again to the women and development community, in and outside the UN, which was leading preparations for the 1995 UN Fourth World Conference on Women (“Beijing Conference”) to ensure that SRRH was included in the draft intergovernmental negotiating document and that the wider feminist community would support SRRH during negotiations (Germain, 1995).
 The facilitator of the negotiation was a HERA member, whose navigation of extremely conflicting views among government delegations was exceptional. Several other government delegates in the negotiation, including me, were also members of HERA.
 IWHC always emphasized, but did not elaborate to the same extent, two other core components of SRRH: maternity care, which received increasing attention from UNFPA and WHO, public health institutions and specialized NGOs; and violence against women, on which WHO produced exceptional technical and programmatic work in collaboration with women’s groups.
 Bangladesh, Brazil, Cameroun, Colombia, India, Indonesia, Nigeria, and the Philippines.
 The 1984 UN Population Conference said that abortion should never be ‘promoted’ as a ‘method of family planning,’ a pronouncement still widely misused by family planning agencies to avoid providing abortion, and by governments to hamper progress on commitment to safe abortion in intergovernmental negotiations.
 In national and global policy arenas during the 1990s, IWHC and allies commonly advocated for safe abortion primarily on health grounds. In the 2000s, recalling the Rio Statement for the ICPD and building on the increasing strength of national and global movements to protect and fulfill the human rights of women, IWHC and allies increasingly voiced both the health and the human rights arguments for abortion access in negotiations and publications.
 The paper reviewed the facts, including the status of national abortion laws worldwide, and highlighted the ICPD and Beijing global agreements.
 Normally, such persuasion is not needed but, in this case, WHO leadership was reluctant to face anti-abortion politics, including threats from its largest donor, the U.S. government. Though many NGO and mainstream IWHC allies were skeptical of success, drawing on longstanding relationships with senior WHO staff, I secured a meeting with WHO’s Director General to persuade her that the 1995 and 1999 UN agreements required action by WHO and to indicate that IWHC’s network would hold WHO accountable for it. Importantly due to US politics at the time, final approval for publication of the guidance took an inordinate amount of time, and WHO leadership, contrary to routine practice, did not disseminate the guidance through their regional offices. Rather, headquarters staff were allowed to distribute the guidance informally and to provide country and regional training in its use only if countries initiated a formal request. Nonetheless, WHO staff and “friends” accomplished considerable distribution, generated training requests and secured translations into UN languages. (IWHC commissioned and funded the Portuguese translation for use in Brazil and other Lusophone countries of the South). In 2012, WHO produced an updated edition of the guidance that reflects, primarily, changes in clinical standards and practice; other technical and policy guidance remained.
 MVA does not require anesthesia, the equipment is sterilized simply with bleach, the procedure normally requires only a few minutes, risk of uterine perforation is very low (the equipment is flexible plastic unlike the metal instruments used in D and C), and the woman recovers quickly.
 Mifepristone, used in combination with another drug such as misoprostol, induces miscarriage of pregnancies up to ten weeks’ gestation. Because Mifepristone is a registered abortion drug, its sale and use are constrained by restrictive laws in many countries. In contrast, misoprostol, an anti-ulcer drug that is widely registered and used, can be used safely on its own to induce miscarriage up to 12 weeks’ gestation, and is an option for women who do not have an accessible and safe alternative. Medication abortion should not be confused with “emergency contraception”, which prevents pregnancy.
 As The Ford Foundation Representative in Bangladesh in the early 1980s, I initiated the first population-based study of “RTIs” in a general population of women in Asia. The expert consultant I engaged for the Bangladesh research, Judith Wasserheit, later became a pivotal consultant for IWHC’s work on RTIs and HIV and AIDS.
 Male condoms require the full cooperation of men. Female condoms did not yet exist, and in any case, would have required men’s cooperation. Barbados meeting participants called for one or more methods totally under a woman’s control that would require neither the knowledge nor the cooperation of her partner.
 Such collaboration was a major innovation for The Population Council, which, like other contraceptive development agencies, had never consulted women activists. They did so in this instance because Sida made it a condition of their funding for the research.
 In 2014, the US government began the $385 million DREAMS partnership, which aims to reduce HIV infections in adolescent girls in the highest-burden areas of 10 African countries by, among others, advancing SRRH and addressing structural drivers such as gender inequality and sexual violence (President’s Emergency Plan for AIDS Relief, 2015).
 WHO leadership was concerned that some conservative member states, including its largest funder, the US government under the Bush Administration, would withdraw funding. In 2015, WHO published paper on sexual health and rights. Like all such WHO publications, the paper does not represent an official WHO “position”, but it is a touchstone, addressing and going beyond the sexual health and rights definition framed by HERA decades earlier (World Health Organization, 2015b).
 From a public health perspective, adolescent girls, especially those under 16, both married and not married, face higher risk of pregnancy wastage, maternal mortality and morbidity, and the consequences of unsafe abortion. Because the partners of married and/or pregnant girls are commonly older and sexually experienced, these girls are also at high risk of RTIs including HIV. From the human rights perspective, the UN Convention on the Rights of the Child protects children from violations such as early and forced marriage, and expulsion from school because of pregnancy or marriage (United Nations General Assembly, 1989).
 As a member of the US government delegation, I negotiated this outcome, initially with delegates of Iran and Pakistan, at the request of the facilitator of an informal negotiating group during the Conference. The price was steep—I agreed to drop the term ‘sexual rights’ from the draft Programme of Action in return for Iran’s and Pakistan’s agreement to protect 42 text references to adolescents’ SRRH from attack by other conservative delegations.
 IWHC staff, Andrea Irvin, continued similar work in Mongolia after leaving IWHC, and the final guidance reflects that experience as well as her years of IWHC work in Nigeria and Cameroun.
 Dixon-Mueller also reviewed the inadequacies of later CSE reviews and guidance from UNESCO (Dixon-Mueller, 2011). IWHC created an abbreviated version of Comprehensive Sexuality Education: Overview and Lesson Plans for Building Effective Programs for UN advocacy.
 Notable examples include: Guttmacher Institute, International Planned Parenthood Federation, PATH, The Population Council, Bulletin of the World Health Organization, The Lancet, and Studies in Family Planning.
 The Facility is intended to close the funding gap for reproductive, maternal, new-born, child and adolescent health by combining a country’s domestic resources, additional external resources and collaboration with the private sector (The World Bank Group, 2016).
 The Center for Reproductive Rights and the International Campaign for Women’s Rights to Safe Abortion are two key organizations providing up to date information and resources on all aspects of access to safe abortion.
 The report of the Special Rapporteur on Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment focuses on the role of sex, gender, and sexuality in the application of the torture and ill-treatment framework. It addresses a range of issues, including abortion, forced and coerced sterilization, abuse of women seeking maternal health care, sexual and domestic violence, and harmful practices, among others.
 In April 2016 the Committee on the Rights of the Child released a “draft General Comment on the implementation of the rights of the child during adolescence” for comment. As of October 2016, the draft can be found at http://www.ohchr.org/EN/HRBodies/CRC/Pages/childduringadolescence.aspx.
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