Chapter 4. Restricted physical integrity

This chapter presents an overview of women’s restricted physical integrity. It examines discriminatory social institutions – formal and informal laws, social norms and practices – that increase women’s vulnerabilities to a range of forms of violence and limit women’s control over their bodies, across 180 countries and covering areas such as violence against women, female genital mutilation, missing women and reproductive autonomy. The chapter also seeks to provide policy makers with the necessary tools and evidence to design effective gender-responsive policies in order to protect women’s physical integrity.

The restricted physical integrity (RPI) sub-index captures social institutions that increase women’s and girls’ vulnerability to a range of forms of violence and limit women’s control over their bodies. This includes formal and informal laws, norms and practices that fail to respect women’s physical integrity, or that serve to normalise and justify practices that impinge upon their reproductive autonomy.

The restricted physical integrity sub-index is composed of four indicators:

“violence against women” (VAW) captures the level of social acceptance and prevalence of domestic violence, as well as its legal acceptance, which is whether the legal framework protects women from violence including intimate-partner violence, rape and sexual harassment, taking into account non-statutory (societal) discrimination against women in traditional, religious and customary laws and practices.
“female genital mutilation” captures the level of social acceptance and prevalence of female genital mutilation (FGM) as well as its legal acceptance, which means whether the legal framework criminalises FGM and includes penalties for practitioners, taking into account non-statutory (societal) discrimination against women in traditional, religious and customary laws and practices.
“missing women” captures the statistical shortfall in the number of girls in the age range 0-4 years, relative to the expected number in the absence of sex-selective abortions, female infanticide or preferential treatment of sons over daughters, correcting for natural biological and physiological differences.
“reproductive autonomy” captures the prevalence of women in reproductive age who have an unmet need for family planning and contraception, as well as legal discrimination against women with respect to their reproductive autonomy rights in case of non-desired pregnancy.

Key messages

Discriminatory social institutions restricting women’s physical integrity includes both universal and region-specific issues:
- The global level of discrimination is 22%;
- Violence against women and restricted reproductive autonomy are universal issues with a respective level of global discrimination of 40% and 31%;
- FGM and the phenomenon of missing women are mainly of concern in Africa and Asia, respectively.
Legal loopholes still fail to protect women from violence and to guarantee them full control over their bodies:
- No legal framework anywhere addresses violence against women in a fully comprehensive way and a third of the world’s women have been victim of domestic violence;
- Abortion on demand is legal in only 61 countries, while 108 countries impose some restrictions and 11 countries maintain complete bans on abortion.
Despite legal frameworks’ increasingly protecting women’s rights, customary laws and social norms still justify harmful practices, such as FGM and sex-selective abortion:
- In the 29 countries where data is available, 23% of women and girls believe FGM should continue and 39% of women and girls aged 15-49 have undergone some form of it;
- The natural sex ratio for ages 0-4 years should not exceed 105 boys per 100 girls, yet it is above 110/100 in Armenia, Azerbaijan, China, India and Viet Nam.

How can governments effectively tackle discriminatory social institutions restricting women’s physical integrity?

Criminalise all forms of VAW, including intimate-partner violence, rape, marital rape and sexual harassment, wherever they occur, such as schools, public spaces and online;
Develop a “whole-of-society” approach to shift social norms and eradicate customary laws justifying FGM;
Shift social norms that can fuel a preference for sons over daughters; and
Legalise abortion with less restrictive justifications and requirements.

Years of advocacy to protect women’s physical integrity, more protective laws and better-designed programmes from governments, civil society, donors and international organisations are starting to produce positive results. The SIGI result for the Restricted Physical Integrity (RPI) sub-index indicates that the global level of discrimination is 22%, ranging from 4% in Canada to 57% in Guinea (Figure 4.1). This is the best score across the four sub-indices of the SIGI.

The relatively good global performance in this dimension hides a mixed picture. FGM and missing women are concentrated in specific areas of the world, automatically improving the RPI score of other countries and, thus, the overall global score. In these two indicators, the global level of discrimination is 6%. However, VAW and restricted reproductive autonomy remain issues with global levels of discrimination, respectively, of 40% and 31% (Figure 4.2). In addition, the global score in the RPI sub-index hides important regional disparities. Europe stands out as the best performer with a score of 13%, while other regions lag behind: the Americas are at 20%, followed by Asia (25%) and Africa (29%).

Canada is the best performer in the restricted physical integrity dimension. The country’s policy response to VAW is one of the most comprehensive in the world and the prevalence rate of VAW (2%) is the lowest globally. Although no data is available on the prevalence of FGM, the practice is criminalised, and no evidence suggests it is widely employed. The sex ratio is balanced, and any woman who wishes to obtain an abortion can do so. However, 7% of women have an unmet need for family planning and 8% think a man can be justified in beating his wife under certain circumstances.

Violence against women

Key messages

No country provides women with comprehensive legal protection from all forms of violence; progress in this regard has been slow. Since the last edition of the SIGI in 2014, 15 countries1 have newly enacted legislation to criminalise intimate-partner violence, bringing to 73% the global proportion of legal frameworks protecting women from this form of violence. Similarly, perpetrators of sexual harassment can now face criminal charges in 61% of countries, thanks to legal reforms in five more countries.2 Countries have, however, been slow to legislate to protect women from emerging forms of gender-based violence. To date, only ten countries or territories provide women with legal protection from cyber harassment or cyber stalking.3
Domestic violence against women is less tolerated. In 2012, 50% of women worldwide declared that spousal violence is acceptable under certain circumstances. This figure dropped to 37% in 2014 and 27% in 2018. Yet, the proportion of condonement remains high and explains why reducing the dramatically high prevalence rates of VAW is an ongoing struggle: VAW is more pervasive in countries where it is more widely accepted.
Despite legal reforms and decreased acceptance, domestic violence is pervasive. On average, 31% of women who have been in a relationship have suffered intimate-partner violence at least once in their lifetime. This proportion has remained unchanged since 2012. Prevalence rates of recent episodes of intimate-partner violence are decreasing slightly. In 2014, 19% of women had suffered assault from their partner in the past year, compared to 14% of women today. This trend holds true for every region.
Canada is the best performer in the VAW indicator. The law protects women from violence, including intimate-partner violence, rape and sexual harassment, without legal exceptions. The country developed several strategies and action plans to address different manifestations of gender-based violence, dedicated mechanisms are in place to finance support services for survivors (such as legal aid or emergency housing) and the prevalence of lifetime intimate-partner violence is the lowest globally (affecting 2% of women). Nevertheless, 8% of women say they are prepared to accept intimate-partner beating.

Key policy recommendations

Provide all women with legal protection from all forms of gender-based violence, notably new forms of violence such as online harassment and stalking, in all places, such as public spaces and schools.
Ensure the effective enforcement of the law. Ensure that women can seek legal redress under the formal justice system and that this right cannot be taken away by traditional, religious or customary laws and practices. Ensure that protection and support services are available for victims of gender-based violence and facilitate women’s access to the law enforcement and justice systems.
Enhance efforts to collect data on the reported prevalence of all forms of VAW among all groups of women to understand better the determinants and patterns of violence and to design evidence-based responses. Administrative data is also crucial to monitoring the proportion of reported crimes actually reaching court and the effectiveness of policies meant to protect survivors of gender-based violence.
Challenge social norms around gender-based violence through media campaigns and awareness-raising activities (Box 4.1).
Policies and interventions must adopt a multi-sectoral approach to ending VAW. For example, supporting women’s access to economic empowerment opportunities can enhance their status within the household or increase their ability to leave abusive relationships.

Box 4.1. International standards on violence against women

Violence against women (VAW) is widely recognised as a fundamental human rights violation. The rights to equality, security, liberty, integrity and dignity of all human beings are enshrined in several international instruments, including:

The Universal Declaration of Human Rights (1948) guarantees to every individual “the right to life, liberty and security of person” (Art. 3);
The Declaration on the Elimination of Violence against Women (1993) calls on States to “pursue by all appropriate means and without delay a policy of eliminating violence against women” (Art. 4);
The Beijing Declaration and Platform for Action (1995) reaffirms that “violence against women is an obstacle to the achievement of the objectives of equality, development and peace” (Art. 112);
SDG Target 5.2 explicitly calls on States to “eliminate all forms of violence against all women and girls”;
The majority of countries reiterated their commitment to end VAW through regional conventions: the Convention of Belém do Pará (1994), the Maputo Protocol (2003) or the Istanbul Convention (2011).

Results

Countries have been slow in implementing comprehensive legal frameworks in line with international standards (Box 4.1) protecting women from all forms of VAW. No country has yet enacted laws to protect women from all forms of violence, without exceptions and in a comprehensive manner. In 35 countries, the law does not comprehensively address VAW: either it does not include specific provisions for investigation, prosecution and punishment of the perpetrator, or it does not provide protection and support services for survivors; or it does not cover physical, sexual, psychological and economic violence; and/or the definition of sexual harassment does not cover the workplace, educational and sporting establishments, public places and cyber harassment or cyber stalking. In addition, in 40 countries, penalties for violence are reduced under certain circumstances, including in cases of marital rape. In 103 countries, the law protects women from some, but not all, forms of violence including intimate-partner violence, rape or sexual harassment. In Equatorial Guinea and the Russian Federation, the law does not protect women from gender-based violence. It is worth noting that, in 11 countries, rape perpetrators can escape prosecution if they marry the victim after the crime.

Since the 2014 edition of the SIGI, little progress has been made in providing state protection from VAW. Forty-eight countries do not have legislation criminalising domestic violence. Over the last four years, 15 countries have enacted new laws addressing the issue.4 Similarly, in 70 countries, perpetrators of sexual harassment do not face criminal charges and only five countries have taken action to address this issue since 2014.5

No country is immune from the pandemic of domestic violence. Globally, 31% of women who have ever had a partner have suffered violence from an intimate partner at least once in their lifetime. This dramatically high proportion has remained unchanged since 2012. Prevalence rates range from 2% of women in Canada to 85% in Pakistan. Intimate-partner violence appears to be more pervasive in low-income countries, where it affects 40% of women, compared to 32% of women in lower middle-income countries, 30% in upper-middle income countries and 23% in high-income countries (Figure 4.3). Asian women are the most likely to suffer from intimate-partner violence (33%), especially women living in Southern Asia (38%).

Discriminatory social norms are often at the origin of high rates of domestic violence. Across the world, 27% of women and girls consider that a husband can be justified in hitting or beating his wife under certain circumstances (if she burns the food, argues with him, goes out without telling him, neglects the children or refuses to engage in sexual intercourse with him). There is a correlation between countries where domestic violence is condoned by a significant proportion of the population and high levels of prevalence of this crime: in Guinea for example, 92% of women justify spousal violence and 80% have suffered from it.

Domestic violence is less prevalent and less tolerated than it was in 2014. In 2014, 19% of women had suffered assault from their partner in the past year, compared to 14% by 2018. This trend is observed in every region of the world and relates to a reduced acceptance of domestic violence. In 2014, 37% of women believed a husband can be justified in beating his wife under certain circumstances, down to 27% four years later. This trend is also verified across all regions.

Current estimates of the prevalence rates of domestic violence might, however, be an understatement of the reality. The stigmatisation of survivors and social norms that consider domestic violence as a private matter prevent women from reporting crimes. Under-reporting is higher among groups of women who are especially vulnerable to VAW, such as indigenous women, migrant women or women with disabilities. In 42 of the 43 countries with recent data, more than 40% of survivors never sought help of any sort. This figure rises to 86% in India (DHS, n.d.[1]). In 35 countries, fewer than 20% of women who had sought help appealed to formal institutions such as the police, medical personnel or lawyers (DHS, n.d.[1]).

Box 4.2. Involving men as fathers and caregivers to challenge social norms around domestic violence in Rwanda

Engaging men as they become fathers and focusing on improving couple’s relationships can be an effective strategy to reduce men’s use of violence against women and improve relationships within the household. A growing body of research highlights how men’s involved caregiving benefits mothers, prevents violence against women and children, and positively impacts family well-being. Based on these findings, Promundo, an international NGO working across 40 countries, together with local partners, developed Program P, a curriculum aimed at engaging men in active fatherhood from their partners’ pregnancies through their children’s early years. Program P was implemented in, among other countries, four districts in Rwanda by the Rwanda Men’s Resource Center, via 15 sessions with expectant fathers and fathers of young children, along with their spouses or partners. Participants performed hands-on activities and role-playing exercises that created a safe environment for discussing and challenging traditional gender norms. Two years later, randomised controlled trial results found that men who participated in the programme were 40% less likely to use violence against their female partners, amongst other positive outcomes (Promundo, 2018[2]).

Source: Promundo (2018[2]), Program P, https://promundoglobal.org/programs/program-p/ (accessed on 20 January 2019).

Female genital mutilation

Key messages

FGM is not universally dealt with as a harmful practice: only 42 countries worldwide abide by international commitments (Box 4.3) and have enacted a comprehensive law criminalising the practice. National legal frameworks vary in scope and enforcement mechanisms. While three countries6 have newly criminalised FGM since 2014, in four countries7 where there are traditional, customary or religious practices encouraging FGM, the law does not take precedence over these practices.
FGM prevalence rates remain high and laws are often poorly implemented notably due to social acceptance of the practice. In the 29 countries where data is available, 23% of women and girls believe it should continue and 39% of women and girls aged 15-49 have undergone some form of FGM, compared to 46% in 2012.
More information is needed on the global prevalence of FGM, which is often perceived as a practice restricted to some African countries. Evidence, however, suggests that FGM is practised across all continents. Countries need reliable and nationally representative data to target interventions to detect and combat FGM efficiently.

Key policy recommendations

Align domestic legislation on FGM with international and regional commitments and standards, especially in countries where FGM is an issue and where migrant populations practice FGM. Criminalise the practice and establish penalties for all perpetrators, including parents and medical practitioners. Add an extraterritorial jurisdiction clause extending penalties to citizens who commit the crime outside of the country (e.g. Kenya has a law penalising its citizens who practice FGM, even when they are beyond its borders8).
Ensure the effective enforcement of the law, by prosecuting perpetrators and providing guidance on prevention, protection, support and follow-up assistance services for survivors.
Mobilise public opinion against FGM and organise information, education and communication interventions on the short- and long- term negative consequences of FGM on women’s and girls’ physical and mental well-being.
Provide key professionals such as health-care personnel, teachers, social workers or immigration officers with adequate training to ensure they can offer advice, support and care to women and girls who have suffered or are at risk of FGM (e.g. United Kingdom’s Multi-agency statutory guidance on female genital mutilation).

Box 4.3. International standards concerning female genital mutilation

FGM is recognised internationally as a harmful practice and a violation of the human rights of women and girls. Since the Vienna World Conference on Human Rights in 1993, FGM has been classified as a form of violence against women (UNICEF, 2013[3]). Several international treaties condemn the practice, including:

The CEDAW; in particular, CEDAW General Recommendation No. 14 (1990) calls on State parties to “take appropriate and effective measures with a view to eradicating the practice of female circumcision” (Para. a);
The Convention on the Rights of the Child (1989) requires State parties to “abolish traditional practices prejudicial to the health of children” (Art. 24);
SDG Target 5.3 explicitly aims to “eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation”;
Commitments on ending FGM also exist in regional instruments such as the Maputo Protocol (2003) or the Istanbul Convention (2011).

Source: UNICEF (2013[3]), “Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change”, https://www.unicef.org/cbsc/files/UNICEF_FGM_report_July_2013_Hi_res.pdf (accessed on 27 January 2019).

Results

Only 42 countries worldwide have enacted a comprehensive criminal law addressing FGM as a harmful practice. Guinea was the first country to criminalise FGM in 1965. It was followed, mostly in the 1990s-2000s, by 21 countries in Africa, 15 in Europe, 3 in Asia and 2 in North America. Recent legal progress has been seen in Croatia (2013), Mozambique (2014), The Gambia and Nigeria (2015). FGM is criminalised in 16 other countries, but in 4 of them, where there is de facto evidence of FGM, the law does not take precedence over customary practices and in 12 countries the law is not backed by sanctions against all perpetrators. International criminalisation of FGM is more important than ever, because it is becoming a cross-border phenomenon, with parents and practitioners going to countries where legislation against FGM is non-existent or poorly enforced to avoid prosecution (WHO, 2016[4]).

Global evidence and information on FGM remain insufficient. SDG Indicator 5.3.2 tracking progress on Target 5.39 is currently available for 29 countries, 27 of them in Africa. Yet, the evidence suggests that FGM is also practised in Europe, Asia and Latin America (EIGE, 2018[5]; UNFPA, 2018[6]).

In the 29 countries where data is available, 39% of women and girls aged 15-49 have undergone some form of FGM (Box 4.4). In other words, more than 200 million girls and women alive today have been cut (UNICEF, 2016[7]). This custom is concentrated in Western and Eastern Africa, some areas of the Middle East and some Asian countries. Its prevalence varies greatly across countries where data is available: from fewer than 2% of women in Cameroon, Niger and Uganda to over 90% in Djibouti, Guinea, Sierra Leone and Somalia.

Men and women who support FGM and find it acceptable are the main obstacle to its elimination, but they can also trigger change. Rates of FGM remain high because of its social acceptance: 23% of women believe that FGM should continue. In Guinea, where FGM has been prohibited since 1965, 67% of women are in favour of its continuation. As a result, 94% of adolescent girls were cut compared with 100% of women aged 45-49 (DHS, n.d.[1]). The practice is widely perceived as a rite of passage for entering adulthood and a determining factor of girls’ marriageability. Decisions are often based on pressure from extended families and communities, rarely involving the girl’s consent (UNICEF, 2013[3]). Nonetheless, communities’ attitudes towards the practice can be a powerful agent of change: in Kenya, where 92% of women believe that FGM should be abandoned, 11% of adolescent girls were cut against 41% of their elders (DHS, n.d.[1]).

Box 4.4. Create the conditions for an effective fight against FGM in Kurdistan, Iraq

Female genital mutilation is widely practiced in the Iraqi Kurdish region, but efforts from civil society are encouraging its elimination. In 2011, 43% of women in the region had been cut compared to 26% of their daughters (UNICEF, 2012[8]).

Co-ordinated by the non-governmental organisation Wadi, the campaign “Stop FGM in Kurdistan” created enabling conditions for effective elimination of the practice (Wadi, 2017[9]).

Data collection on the prevalence of the practice raised awareness of the issue in 2004. Through education, advocacy and lobbying initiatives, a network of local and international organisations, human rights activists, artists and journalists, supported by local media, then managed to turn FGM into a publicly debated issue. Mobile teams raised awareness among women about the medical and psychological consequences of the practice. A film and several television spots also spread information and public screenings provided opportunities to discuss the issue.

The campaign also managed to draw political attention to the problem. It submitted a petition to the regional parliament containing over 14 000 signatures to ban FGM and recommendations for a draft law. As a result, the parliament passed a law criminalising the practice in 2011 (Act of Combating Domestic Violence in Kurdistan Region, Art. 2 & 6). In 2011, fewer than 12% of women who knew about the practice thought it should continue (UNICEF, 2012[8]).

Sources: UNICEF (2012[8]), Iraq Multiple Indicator Cluster Survey 2011 Final Report, https://mics-surveys-prod.s3.amazonaws.com/MICS4/Middle%20East%20and%20North%20Africa/Iraq/2011/Final/Iraq%202011%20MICS_English.pdf (accessed on 20 January 2019); Wadi (2017[9]), “The campaign against female genital mutilation”, https://wadi-online.org/2017/03/06/the-campaign-against-female-genital-mutilation/ (accessed on 28 January 2019).

There is evidence that the practice of FGM is declining overall, but progress is uneven. In 2012, 46% of women and girls aged 15-49 had undergone FGM, compared with 39% in 2018. In Ethiopia in 2016, 79% of women aged 45-49 were cut, against 47% of adolescent girls (aged 15-19). Yet, in other countries, such as Gambia, where the practice affects adolescent girls and older women in the same proportion (76%), FGM prevalence is stagnating (DHS, n.d.[1]). The pace of decline, in fact, has been uneven and depends on the country. In Kenya for example, the FGM prevalence rate decreased by 11 percentage points in 11 years (from 32% of women aged 15-49 in 2003 to 21% of the same age group in 2014), while in Senegal the reduction was only 3 percentage points over the same period (from 28% in 2005 to 25% in 2014) (DHS, n.d.[1]).

No country in the world where FGM is historically practised has successfully eliminated it, but hope remains (Box 4.4). In Kenya, adolescents are four times less likely to be cut than their elders. This relatively favourable environment is the outcome of several measures: the prohibition of FGM in 2001 and reaffirmed in 2011, several national action plans and policies taking into account the crucial role of community support for the elimination of FGM, training of police officers and community leaders on the implementation of the legislation, media campaigns and awareness-raising interventions (The Girl Generation, 2016[10]).

Missing women

Key messages

The systematic under-valuing of women and girls has led to a deficit in the number of girls and women alive today in some Eastern Asian, Central Asian and Southern Asian countries. The natural sex ratio for ages 0-4 should not exceed 106 boys for 100 girls, yet it is above 110/100 in Armenia, Azerbaijan, China, India and Viet Nam.
The problem occurs in fewer than 5% of countries but they contain 39% of the global population and 38% of the world’s women.
Government interventions and shifting social norms have led to a slight decline in the missing women phenomenon over the past decade. In four of the five countries where the problem is most acute, there has been a slight-to-moderate decrease in the sex ratio for ages 0-4 since the beginning of the century. The case of Korea highlights the feasibility of eliminating social norms biased toward sons (Box 4.6).

Key policy recommendations

Adopt comprehensive strategies to help shift son-biased social norms. Enact non-discriminatory legislation to address the root causes of son preference: grant women and men the same legal status, rights and responsibilities in the family and society, particularly in areas such as marriage, inheritance, dowries, family headship or parental authority. Provide social protection to the most vulnerable, particularly the elderly. Take effective measures to ensure men and women have equal access to the economic and political spheres.
Implement temporary policy measures until broad policy efforts to shift son preference take effect. Where the sex ratio is imbalanced at birth, introduce laws to restrict the use of technology for sex-selection purposes. Where the sex ratio is imbalanced among young age cohorts, introduce measures such as direct subsidies at the time of a girl’s birth, scholarship programmes targeting girls, gender-based school quotas or financial incentives, or pension programmes for families that only have girls (e.g. in India, the government offers cash incentive schemes for families to send their daughters to school; these schemes have caused parents to view their daughters as less “burdensome”).

Box 4.5. International standards concerning the rights of the girl child

States have an obligation to eliminate discriminatory practices leading to the phenomenon of “missing women”. The concept was first introduced by Amartya Sen in the late 1980s. He hypothesised that over 100 million women were missing due to excess female mortality resulting from inequality and neglect (Sen, 1990). Yet, sex selection is prohibited under several international treaties:

The “right to life” is guaranteed to every individual under several international treaties including the Universal Declaration of Human Rights (Art. 3, 1948) or the International Covenant on Civil and Political Rights (Art. 6, 1966);
The Convention on the Rights of the Child (1989) also recognises that “every child has the inherent right to life” and calls on State parties to “ensure to the maximum extent possible the survival and development of the child” (Art. 6);
The CEDAW (1979) requires state parties to “modify the social and cultural patterns of conduct of men and women, with a view to achieving the elimination of […] practices which are based on the idea of the inferiority or the superiority of either of the sexes” (Art. 5);
The Programme of Action adopted during the International Conference on Population and Development (Cairo Conference, 1994) enjoins “leaders at all levels of the society [to] speak out and act forcefully against patterns of gender discrimination within the family, based on preference for sons” (Action 4.17).

Results

The systematic under-valuing of women and girls has led to a deficit in the number of women alive today. Manifestations of missing women are concentrated in some Eastern Asian, Central Asian and Southern Asian countries. The natural sex ratio for ages 0-4 is around 106 males/100 females (WHO, 2011[11]). Yet, it is above 108 in Georgia, Hong Kong, China and Chinese Taipei and above 110 in Armenia, Azerbaijan, China, India and Viet Nam (Figure 4.5). In these countries, skewed sex ratios peaked between 2000 and 2010.

The phenomenon of missing women is driven by traditional stereotypes regarding men’s and women’s roles in the society. Many societies consider boys as a lifelong economic resource, while girls are seen as a liability (OECD, 2012[13]). In some countries, sons are expected to provide for their parents upon their retirement, whereas girls, once married, will contribute to their in-laws’ families instead. Social institutions, such as dowry, also encourage sex selection. Sons may be associated with higher social prestige and perpetuation of the ancestral line and family name. Other factors explaining this phenomenon include increasing access to technologies that can be used for sex selection, combined with restrictive family planning policies such as China’s one child policy (in effect until 2015) (OECD, 2012[13]).

Government interventions and shifting social norms have led to a slight decline in the missing women phenomenon in the past decade. In most countries with evidence of discrimination, there has been a slight to moderate decrease in the sex ratio for ages 0-4 over the last decade, indicating a decrease in the number of missing women (Figure 4.5). The exception has been Viet Nam, where the sex ratio for ages 0-4 has increased from 106 in 2005 to 111 in 2015. This trend in Viet Nam appears to be driven by a lower fertility rate, combined with a cultural preference for boys, together with increased and cheaper access to technologies to determine the sex of unborn foetuses and to sex-selective abortions (World Bank, 2011[14]). However, in other countries, legal and policy measures to address the status and value given to women and girls have had a positive effect (Box 4.5).

Box 4.6. Reversal of skewed sex ratios through legal reforms and mass media campaigns in Korea

In Korea, the sex ratio at birth was 107 in 2015, a number close to expectations. Yet, the ratio was as high as 114/100 over the period 1985-95 (UNDESA, 2017[12]). This imbalance was the manifestation of a deeply rooted preference for sons that has weakened as a result of a combination of factors.

In an effort to reduce the incidence of sex-selective abortions, Korea enacted a law in 1987 making it illegal for a doctor to reveal the sex of a foetus to expecting parents. Successive legal reforms, notably in 1991 and 2005, granted women the same legal rights as men regarding marriage, inheritance, family headship and parental authority. The government also organised media campaigns to discourage sex-selective abortions.

In parallel, socio-economic development, greater urbanisation, higher female access to education and participation in the formal labour force and a strengthened old-age pension system have triggered a weakening of social norms regarding son preference, and an increase in the status and value of women and their greater autonomy (Chung and Das Gupta, 2007[15]). As a result, while 48% of ever-married women declared that having a son was a necessity in 1985, this percentage decreased to 8% in 2012 (Korea Institute for Health and Social Affairs, 2012[16]).

Sources: UNDESA (2017[12]), “World Population Prospects: The 2017 Revision, DVD Edition”, https://www.un.org/development/desa/publications/world-population-prospects-the-2017-revision.html (accessed on 27 January 2019); Chung, W. and M. Das Gupta (2007), “Why is son preference declining in South Korea? The role of development and public policy, and the implications for China and India”, https://openknowledge.worldbank.org/handle/10986/7367 (accessed on 26 January 2019); Korea Institute for Health and Social Affairs (2012), “The 2012 National Survey on Fertility, Family Health & Welfare in Korea”, https://www.kihasa.re.kr/english/publications/eng_research/view.do?ano=717&menuId=68&tid=34&bid=30 (accessed on 27 January 2019).

Reproductive autonomy

Key messages

Women’s reproductive autonomy rights in case of non-desired pregnancy are often threatened by discriminatory laws. Abortion on demand is legal in only 61 countries, while 108 countries impose some restrictions and 11 countries maintain complete bans on abortion.
Poor health-service infrastructure, lack of information and persisting social institutions that limit women’s control over their bodies have prevented progress in this area since 2012: around the world, 12% of women of reproductive age (15-49) report having an unmet need for family planning, and up to 24% of women in sub-Saharan Africa suffer from this insufficiency of service.
China and France are the best performers in this indicator. In both countries, abortion on demand is legal and a low proportion of women (4%) have an unmet need for family planning.

Key policy recommendations

Secure women’s and girls’ sexual and reproductive health and rights so that they are not forced to seek unsafe medical procedures such as illegal abortion. Ensure all women have affordable and secure access to high-quality and culturally accepted family planning and health information and services. Public/private partnerships can broaden access through, for example, subsidised family planning service delivery by private entities (as is the case in Papua New Guinea), publicly funded voucher programmes (as in Pakistan), or information campaigns (such as those in Tanzania) (Mangone and Gitonga, 2017[17]).
Adopt a human rights-based approach to sexual and reproductive health and rights that safeguards the reproductive autonomy of women and acknowledges that women’s decisions about their own bodies are personal and private. Enable women who wish to do so obtain legal abortions within defined gestational periods.
Despite their private nature, women’s sexual and reproductive health and rights are a divisive topic in many societies. Dialogue is key to ensure that laws will be understood, accepted and enforced (Box 4.8).

Box 4.7. International standards on women’s reproductive autonomy

Women’s sexual and reproductive health and rights are enshrined in several international treaties:

The CEDAW (1979) calls on State parties to ensure, on a basis of equality of men and women, “the same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights” (Art. 16);
In 1994, 194 governments, gathered at the International Conference on Population and Development (Cairo Conference), recognised that “ensuring women’s ability to control their own fertility [is a] cornerstone of population and development-related programmes” (UN, 1994[18]);
The Beijing Declaration and Platform for Action (1995) reaffirms that the rights of women “include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health” (Art. 96);
More recently, the necessity to ensure universal access to “sexual and reproductive health-care services” (SDG Target 3.7) and to “sexual and reproductive health and reproductive rights” (SDG Target 5.6) has been integrated to the SDG framework.

Source: UN (1994), “Report of the International Conference on Population and Development”, https://www.ipci2014.org/sites/ipci2014.org/files/icpd_eng.pdf (accessed on 27 January 2019).

Results

Women’s reproductive autonomy rights in the case of non-desired pregnancy are often threatened by discriminatory legal frameworks. Despite international standards calling on states to guarantee women’s rights to control their fertility (Box 4.7), statutory law allows medical abortion on demand (within a gestational limit) in only 61 countries. However, most countries (108) have put conditions on legal abortion. In those countries, the conditions include saving the woman’s life (108 countries), in cases of rape, statutory rape or incest (48 countries), foetal impairment (44 countries) or preservation of the physical (61 countries) or mental (40 countries) health of the woman. In addition, 11 countries have complete bans on abortion.

Legal grounds for abortion vary greatly among regions and little change has been seen since 2014. Abortion on demand is legal in 83% of European countries, compared with 31% in Asia, 16% in the Americas and 11% of African countries (Figure 4.6). Only one country in Europe (Malta) and no country in Asia completely prohibits abortion, compared with 11% of countries in Africa10 and 13% in the Americas.11 Over the four years to 2018, two countries have legalised abortion on demand (Luxembourg and Mozambique) and three countries have extended the grounds on which abortion is permitted (Chad, Chile and Eritrea).

No country in the world guarantees universal access to contraception and no progress has been made in this regard. Some 12% of women of reproductive age (15-49) report having an unmet need for family planning. This proportion has not decreased since 2012. The gap between women’s reproductive intentions and their contraceptive behaviour ranges from 9% in Europe to 22% in Africa. In 52 countries, 32 of which are located in sub-Saharan Africa, more than 20% of women have an unmet need for family planning. However, in absolute numerical terms, the majority of women with an unmet need for family planning live in South Asia.

Women’s low reproductive autonomy is connected to poor health-service infrastructure, lack of information and discriminatory social institutions that limit women’s control over their bodies. One in four women is reported to have an unmet need for family planning in low-income countries, double the world average. Poor women and women living in rural settings often face greater difficulties in accessing reproductive health services, as poverty and remote locations compound their already limited resources (UNFPA, 2012[19]). Additional barriers include lack of knowledge about contraceptive methods and sources of supply or incorrect perceptions about the health risks of modern methods. Demographic survey data of women’s self-reported reasons for non-use of contraceptive methods highlight that social acceptability is a key driver. More than 4% of women with an unmet need do not use a contraceptive method because of their partner’s opposition or religious prohibition (DHS, n.d.[1]).

Box 4.8. Enable citizens’ direct participation in decision-making in Ireland

In May 2018, the Irish people decided in a referendum to repeal and replace the Eighth Amendment of the Irish Constitution Act of 1983, which regulated the termination of pregnancies by recognising an equal right to life of the woman and the unborn child. The issue was highly contentious at the outset but involved a highly transparent consultation process that fuelled a desire for reform. A Citizens’ Assembly considered five major constitutional issues, including the Eighth Amendment. The Assembly heard from expert witnesses, women affected by the existing legislation and from advocacy and representative groups, as well as from ordinary Irish citizens and non-citizens. The result was that 87% of the Assembly members recommended in their report that the rules covering abortion should be relaxed by repealing and replacing the 8^th Amendment, a position ultimately adopted by a joint committee of the Houses of the Oireachtas (the Irish Parliament). The joint committee brought forward the referendum and repeal was supported by a majority of 66.4% of the vote (Citizen's Assembly, 2017[20]). On December 2018, the Health (Regulation of Termination of Pregnancy) Bill was promulgated, making abortion legal during the first 12 weeks of pregnancy (Oireachtas, 2018[21]).

Sources: Citizen's Assembly (2017), “Opening Speech for Chair for Joint Oireachtas Committee on the Eighth Amendment”, https://www.citizensassembly.ie/en/The-Eighth-Amendment-of-the-Constitution/Address-given-by-the-Chair-Justice-Laffoy-Meeting-of-the-Joint-Committee-on-Eighth-Amendment-of-the-Constitution.pdf (accessed on 26 January 2019); Oireachtas (2018), “Heatlh (Regulation of Termination of Pregnancy) Act”, https://data.oireachtas.ie/ie/oireachtas/act/2018/31/eng/enacted/a3118.pdf (accessed on 27 January 2019).

References

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[20] Citizen's Assembly (2017), Opening Speech for Chair for Joint Oireachtas Committee on the Eighth Amendment, https://www.citizensassembly.ie/en/The-Eighth-Amendment-of-the-Constitution/Address-given-by-the-Chair-Justice-Laffoy-Meeting-of-the-Joint-Committee-on-Eighth-Amendment-of-the-Constitution.pdf (accessed on 26 January 2019).

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Notes

← 1. Comoros, Former Yugoslav Republic of Macedonia (now the Republic of North Macedonia), Lao People’s Democratic Republic, Lebanon, Solomon Islands (2014), Algeria, Antigua and Barbuda, Bahrain, Kenya, Netherlands, People’s Republic of China (2015), Barbados (2016), Moldova, Mongolia and Tunisia (2017).

← 2. Egypt (2014), Afghanistan, Cameroon, Guinea (2016) and Chad (2017).

← 3. Austria, El Salvador, Former Yugoslav Republic of Macedonia (now the Republic of North Macedonia), Honduras, Malaysia, Sierra Leone, South Africa, Chinese Taipei, United States, Zimbabwe.

← 4. Comoros, Former Yugoslav Republic of Macedonia (now the Republic of North Macedonia), Lao People’s Democratic Republic, Lebanon, Solomon Islands (2014), Algeria, Antigua and Barbuda, Bahrain, Kenya, Netherlands, People’s Republic of China (2015), Barbados (2016), Moldova, Mongolia and Tunisia (2017).

← 5. Egypt (2014), Afghanistan, Cameroon, Guinea (2016) and Chad (2017).

← 6. Mozambique (2014), Gambia and Nigeria (2015).

← 7. Cameroon, Nigeria, Uganda and Tanzania.

← 8. Prohibition of Female Genital Mutilation Act, 2011.

← 9. SDG indicator 5.3.2 (“Proportion of girls and women aged 15-49 years who have undergone female genital mutilation/cutting, by age”) is one of the two indicators that measure progress against SDG target 5.3 (“Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation”).

← 10. Gabon, Guinea-Bissau, Madagascar, Mauritania, Republic of the Congo and Senegal.

← 11. El Salvador, Haiti, Honduras and Nicaragua.

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