state state of world population 2019 UNFINISHED BUSINESS: the pursuit of rights and choices for all ISSN 1020-5195 ISBN 978-0-89714-029-4 UNFINISHED Ensuring rights and choices for all since 1969 United Nations Population Fund 605 Third Avenue New York, NY 10158 +1 (212) 297-5000 BUSINESS www.unfpa.org Sales No. E.19.III.H.1 the pursuit of rights and choices FOR ALL @UNFPA E/4,221/2019 Printed on recycled paper. State of World Population 2019 This report was developed under the auspices ACKNOWLEDGMENTS of the UNFPA Division of Communications UNFPA thanks the following women for sharing glimpses and Strategic Partnerships. of their lives for this report: Tefta Shakaj, ALBANIA EDITOR-IN-CHIEF Mediha Besic, BOSNIA AND HERZEGOVINA Arthur Erken, Director, Division of Communications Tsitsina Xavante, BRAZIL and Strategic Partnerships Say Yang, CAMBODIA Dahab Elsayed and Um Ahmed, EGYPT EDITORIAL TEAM Alma Odette Chacón, GUATEMALA Editor: Richard Kollodge Marta Paula Sanca, GUINEA-BISSAU Editorial associate: Katie Madonia Fanie Derismé, HAITI Digital edition manager: Katie Madonia Rajeshwari Mahalingam, INDIA Digital edition advisers: Hanno Ranck, Katheline Ruiz Shara Ranasinghe, SRI LANKA Publication and web design: Prographics, Inc. Rasamee, THAILAND Josephine Kasya, UGANDA RESEARCH ADVISER AND WRITER Stan Bernstein The editors are grateful to William McGreevey for research on institutional and financing obstacles to sexual and reproductive UNFPA TECHNICAL ADVISERS health and to Christopher Hook for other research assistance. Elizabeth Benomar The Population and Development Branch of UNFPA aggregated Daniel Schensul regional data in the indicators section of this report. Source data for the report’s indicators were provided by the Population LEAD RESEARCHER AND WRITER Division of the United Nations Department of Economic and Kathleen Mogelgaard Social Affairs, the United Nations Educational, Scientific and Cultural Organization and the World Health Organization. CHAPTER RESEARCHERS AND WRITERS Rachel Snow, Sara Reis and Marielle Sander-Lindstrom from Jeffrey Edmeades UNFPA also contributed to the shaping of this year’s report. Gretchen Luchsinger Erin Anastasi, Emilie Filmer-Wilson, Anneka Knutsson and William A. Ryan Leyla Sharafi reviewed and commented on drafts. Ann M. Starrs MAPS AND DESIGNATIONS FEATURE WRITERS The designations employed and the presentation of material Janet Jensen in maps in this report do not imply the expression of any Gretchen Luchsinger opinion whatsoever on the part of UNFPA concerning the legal status of any country, territory, city or area or its authorities, © UNFPA 2019 or concerning the delimitation of its frontiers or boundaries. A dotted line approximately represents the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not been agreed upon by the parties. PHOTOGRAPHY Front cover: © Steve McCurry/Magnum Photos Timeline: © Alamy Stock Photos, Getty Images, Jangbu Sherpa, Warren K. Leffler, NASA, UN/UNFPA Ensuring rights and choices for all since 1969 UNFINISHED BUSINESS the pursuit of rights and choices FOR ALL The struggle for rights and 1 choices is an ongoing one page 7 Six women, six decades, six journeys 2 page 23 Rights at risk in times of population growth 3 page 37 Available but 4 inaccessible page 53 The obstacle underlying all others 5 page 73 When services collapse 6 page 87 Institutions and funding to ensure rights and choices 7 page 101 Realizing rights and choices for all: If not now, when? 8 page 117 More than my mother, 9 less than my daughter page 137 © Cristina Garcia Rodero/Magnum Photos Remarkable gains have been made in sexual and reproductive health and rights since 1969, when UNFPA was established. But despite progress, hundreds of millions of women today still face economic, social, institutional and other barriers that prevent them from making their own decisions about whether, when, how often and with whom to become pregnant. The pursuit of rights and choices is an ongoing one, with new challenges emerging all the time. FOREWORD Make rights and choices a reality for all It was 1969. World population reached 3.6 billion, Since its creation in 1969, UNFPA has led a up about 1 billion from only 17 years earlier. Fertility multilateral effort to help women in developing rates worldwide then were about double what they countries navigate through an ever-changing are today. In the least developed countries, fertility landscape of barriers to their reproductive rights. was about six births per woman. This effort gained new momentum and inspiration in 1994, when 179 governments gathered in Cairo Paul Ehrlich’s The Population Bomb, released the for the International Conference on Population and year before, had incited a global panic about Development and forged a plan for sustainable “overpopulation,” which the author predicted would development grounded in individual rights and lead to mass starvation on a “dying planet.” choices and the achievement of sexual and reproductive health for all. That plan, embodied It was in that context that UNFPA was established in a Programme of Action, not only re-energized to advise developing countries about the social the global reproductive rights movement but also and economic implications of population growth positioned UNFPA as the movement’s custodian. and to support national population programmes, which began dispensing contraceptives on an The combined actions of civil society, governments, unprecedented scale. development institutions and UNFPA over the past 50 years have unlocked opportunities and Through these programmes, real reproductive possibilities for women and girls across the globe. choices became a reality for more and more Yet, we still have a long way to go before all women women in developing countries. And as a result, and girls have the power and the means to govern women started having fewer children. Millions their own bodies and make informed decisions about were finally gaining the power to control their their sexual and reproductive health. own fertility. At the same time, we must push back against forces Despite the increasing availability of contraceptives that would see us return to a time when women over the years, hundreds of millions of women had little say in reproductive decisions or, for that today still have no access to them—and to the matter, in any area of their lives. reproductive choices that come with them. Without access, they lack the power to make The fight for rights and choices must continue until decisions about their own bodies, including they are a reality for all. whether or when to become pregnant. Dr. Natalia Kanem The lack of this power—which influences so United Nations Under-Secretary-General many other facets of life, from education and Executive Director of UNFPA, to income to safety—leaves women unable the United Nations Population Fund to shape their own futures. 4 © Digby Oldridge/PR Eye Bespoke Photography 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 © Gilles Peress/Magnum Photos CHAPTER 1 THE STRUGGLE FOR RIGHTS AND CHOICES IS AN ONGOING ONE The year 2019 marks two important milestones in the field of reproductive health: 50 years since UNFPA began operations, and 25 years since the landmark International Conference on Population and Development (ICPD) in Cairo. These two events—the launch of the and families, and the societies in What the future holds in terms first United Nations agency dedicat- which they live, in ways measurable of changes in population growth, ed to addressing population growth and immeasurable, profound and contraceptive use and sexual and and the reproductive health needs trivial, permanent and fleeting. reproductive health and rights will of the world’s people, and the dec- Activists, advocates, public health both determine and be determined laration of a global commitment to specialists and many others have by the ability of women and girls to sexual and reproductive health and pushed relentlessly for the trans- achieve their full potential as mem- reproductive rights—have funda- formations we see around us today, bers of their societies. And this will mentally shaped the lives of women but much remains to be done. be determined, in no small part, by STATE OF WORLD POPULATION 2019 7 how the world takes forward the women were using some form of the world, and the women’s lib- achievements and addresses the contraceptive method to delay or eration movement was fighting shortfalls of the ICPD to date. prevent pregnancy; in the least for equality in access to educa- developed countries, however, tion, employment opportunities The world in 1969 the average woman had 6.7 chil- and pay, marriage and divorce, Fifty years ago around the world, dren, and about 2 per cent were property ownership, and on a the average woman had 4.9 chil- using a method of contraception. range of other fronts. In 1969, dren, and 35 per cent of married Abortion was illegal in much of the Stonewall Riots in New York 1969 TO2019 ▲ RAFAEL SALAS NAMED The United States ▲ UNFPA EXECUTIVE DIRECTOR and Soviet Union The bridge in Istanbul Nuclear GENERAL ASSEMBLY join 70 other nations that crosses the Bosphorus WORLD THE UNITED NATIONS FUND Non-Proliferation DESIGNATES UNFPA in signing an is completed, connecting