The biggest demographic challenge and opportunity of the

The biggest demographic challenge and opportunity of the region is its enormous population of youth. About 850 million people in Asia and the Pacific are between the ages of 10 and 24 = More than half of the world's young people This demographic surge of people entering their productive and reproductive years is great potential for development - if countries invest wisely in the education, health, skills and economic opportunities of youth.

Asia is also home have a very fast growing aged population, most of whom will be women. People > 60 made up about 9. 3% of the region's population in 2005 and are projected to account for almost 15% by 2025 Major challenge will be the provision of old age security and health insurance for the elderly.

The population growth rate for Asia and the Pacific is now close to the world's average (1. 21 per 1, 000 population), with some countries having reached fertility levels of 2. 1 or below. However, high fertility in some countries, especially in South and West Asia, continues to outpace economic and development gains and stall poverty reduction efforts. The large percentage of young people means that the region will continue to grow for years to come, although some Pacific island countries are losing population and capacity, due to migration

Within the next 15 years, 18 of the projected 27 megacities (urban areas with more than 10 million people) will be in Asia, and over half of the people will live in slums and informal settlements. This urbanization poses serious environmental threats, including high levels of water and air pollution and attendant health risks.

Urbanization is occurring at an unprecedented pace, bringing with it both problems and possibilities. Nearly 40 million people in the region, many of them women and young people, migrate each year to urban areas in search of economic opportunity. The majority end up living in slum-like conditions characterized by insecure tenure, inadequate housing and a lack of access to water or sanitation.

People Living with HIV/AIDS Generally poor and voiceless in society They as well as their families are discriminated against. Do not receive the care and support they need They need support not pity to live

…a powerful duo } Stigma = attitude Personal } Discrimination= action Attaches to pre-existing stigmas } Cycle of shock, shame, secrecy, silence…

The lifetime risk of maternal death in Asia is 18 times greater than in Europe. (UNFPA) but within Asia Pacific it is also very different between countries. Maternal Mortality Rates: Australia – 6 per 100, 000 life-births Malaysia – 30 per 100, 000 life-births PNG - 390 per 100, 000 life-births Indonesia - 470 per 100, 000 life-births Laos - 650 per 100, 000 life-births

Every year 30 000 -50 000 mothers die from the complications of pregnancy or childbirth. More than 40% of all maternal deaths occur in five countries (Cambodia, the Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam) whose combined populations account for only 10% of the Region' s population. (WHO) There also huge variations in rates within countries. For example, national data in the Lao People's Democratic Republic for 1995 reveal a MMR of 150 in Vientiane and over 9000 in more remote provinces.

GENERAL FACTORS THAT CONTRIBUTE TO MATERNAL DEATH • About 80% of maternal deaths are due to causes that are directly related to childbirth and pregnancy. • The five major direct causes of maternal deaths are – – – Hemorrhage Sepsis Hypertension disorders Prolonged or obstructed labor Unsafe abortion.

• About 20% of maternal deaths arise from pre-existing conditions that are aggravated by pregnancy. • The indirect causes of maternal deaths are – Cardiovascular system – Infections (excluding puerperal sepsis) – Connective tissue disease – Place of delivery – substandard care

Approximately 20% of maternal deaths arise from pre-existing conditions that are aggravated by pregnancy such as –Anemia –Malaria –Hepatitis –Heart disease –HIV/AIDS.

Persistently low levels of contraceptive use are found in some Countries Emergency Contraceptive not easily available Among the prominent cultural barriers preventing men, women and the youth from accessing RH services are those, which are gender-related. Many of the barriers are rooted in gender inequalities that restrict women’s access to income, mobility, decision-making power, that together culminate in a general lack of empowerment.

Worldwide, every minute, 100 women have an abortion, 40 of which are unsafe About 14 unsafe abortions occur for every 100 live births in Asia. Excluding East Asia, where safe abortion is widely accessible, one unsafe abortion occurs for every 5 live births. Source: Ahman, Elisabeth and Iqbal Shah. 2002. Unsafe abortion: Worldwide estimates for 2000. Reproductive Health Matters 10(19): 13 -17.

• Unsafe abortion is a major threat to women's health: • About 1/3 of women who have unsafe abortions experience complications that pose major risks to their lives and health. • The WHO estimates that unsafe abortion is responsible for 13% of all maternal deaths globally. About 70, 000 women die each year from complications of unsafe abortion. • Millions more women suffer from debilitating complications and illness, e. g incomplete abortion, tears in the cervix, perforation of the uterus, fever, infection, septic shock, and severe hemorrhaging.

Maternal Mortality is inversely proportionate to the percentage of deliveries by skilled attendants.

ARROW: Monitoring Ten Years of ICPD Implementation “The Way Forward” pg. 30

Poverty increases the risk of maternal Mortality due to lack of access to good quality health care

Challenges of growing numbers of young people in the region Programs designed by adults may not be suitable for the young Adults regard the young as a problem while the young want adults to treat them as a solution Should/can sex education be provided before they drop out of school Right to contraception before Marriage? ?

ØGender inequality and cultural vulnerability are two issues that constitute particular challenges ØGender disparities persist in the areas of health, literacy, education, political participation, income and employment. As a result, many women, especially those who are impoverished, are prevented from exercising their human rights and realizing their full potential. Their families, communities and countries miss out as well. ØA combination of cultural and institutional barriers is implicated in the root causes of poverty, reproductive ill-health and indicators of the poor socio-economic status of women.

ØSexual double standards are part of the masculinity norm, resulting in negative reproductive health consequences for women, which are manifested in many forms. For example, in cultures where virginity is highly valued, unmarried young women may be persuaded to engage in anal sex or other practices that preserve their virginity, but place them at higher risk of infection Ø. Virginity norms may also make young women reluctant or ashamed to seek treatment for reproductive tract infections (RTIs). On the other hand, masculinity norms as expressed in macho complexes lead men to engage in reckless behaviors such as having multiple sex partners, patronizing sex workers and perpetrating violence. ØIn Thailand, it is reported that young men’s infidelity is generally accepted such that if a young man does not patronize prostitutes he would be thought to be homosexual

Ø Chauvinist cultural views on sexuality, including the perception of female sexuality as being passive, devoid of desire and subordinate to male needs; prescription of virginity and sexual monogamy for women while condoning multiple sexual partners for men before and during marriage; and to the norm of conjugal sexuality as being mainly oriented towards reproduction. Ø The association between women’s empowerment and improved reproductive health and child health – through education, employment, decisionmaking, access to social services and credit facilities, for example – is strong testimony to the dividends that accrue from investing in gender equality.

q. Cultural Expectations of roles within relationships q. Belief in the inherent superiority of males q Values that give men proprietary rights over women and girls q. Notion of the family as the private sphere under male control q Customs of marriage, (bride price/dowry) q Acceptability of violence as a means to resolve conflict

q. Although most countries in the region have signed or ratified the UN Convention on the Elimination of All Forms of Discrimination against Women, not all ensure equal rights for women in their own constitutions. Gender-based violence remains widespread and has only recently been recognized as a significant public health and development concern. q A strong preference for sons in some countries has led to pre-natal sex selection or neglect of infant girls, with the result that least 60 million girls are 'missing' in Asia, with potentially serious social consequences.

§The ESEA region has become a target for sex tourism and trafficking of women, and children for many reasons, but chiefly for sexual purposes. § Due to unequal gender relations, sex work tends to be a highly stigmatized profession, with female sex workers at risk of prosecution, whilst male clients are free to buy sexual services with impunity, and are often regarded as being quite ‘normal’ for doing so.

üTrafficked women are likely to be amongst those with least access to reproductive health information and services. üMany of them are highly vulnerable to sexual abuse and physical violence, unwanted pregnancy, STDs and HIV/AIDS due to the nature of the work they end up doing at their destination points. üDue to their social and legal ‘invisibility’ they often have no way of accessing health care.

§ Because of cultural definition of men’s perceived physical needs, in most of the ESEA countries it is quite acceptable for men to visit prostitutes, or even to have second, ‘minor’ wives § Whilst virginity is highly rated in a bride and monogamy within marital relationships, men are nevertheless perceived as needing an outlet for their sexual urges. Hence there is tacit approval for prostitution in most countries in the region §Sex workers themselves however are generally looked down on and are regarded as a necessary social evil, whilst the legal status of commercial sex work varies between countries.

Main Trafficking Routes Countries of Origin Cambodia China Lao PDR Myanmar Thailand Viet Nam Transit Countries Cambodia Myanmar Thailand Countries of Destination Cambodia China Thailand Singapore Taiwan Malaysia Hong Kong Japan Source: UNIFEM. East and South-East Asia Regional Office and UNIAP. Trafficking in Persons: A Gender and Rights Perspective. Briefing Kit.

Under cultural vulnerability, reference is made to: i) ethnic and religious minorities, two of the key groups that are often outside of the mainstream socio-cultural setting in a country and ii)groups who practice or are exposed to risky reproductive and sexual beliefs and practices. These two sets of groups are often subject to discrimination of some form or another Drug Users Sex Workers Migrant workers Single mothers MSM PLWHAs The Indigenous

. v. Service providers sometimes reflect their own cultural or religious values, particularly when dealing with sensitive issues such as unwanted pregnancies and contraceptives. In Indonesia service providers seemed to be more tolerant towards clients wishing to terminate unwanted pregnancies due to contraceptive failure, rather than for other reasons. In all cases, however, continuation of the pregnancy was usually recommended

v. In Myanmar many health providers felt they should scold the clients who came in for post-abortion complications, and that this scolding was in the interest of the clients in order to keep them from seeking abortions in the future. Many village women delayed seeking help for even severe complications due to fear of being reprimanded, as well as fear of neighbors finding out about the abortion v. In a survey carried out among formal and informal sector health providers in Lao PDR, 18 percent of the providers considered it their duty to inform the parents of their children’s sexual activity. They hoped that the parents could exert influence on their children to refrain from sexual relationships.

o. The religious and/or spiritual frameworks within which most communities operate can be an important entry point for reproductive health programming. o. Issues relating to sexual and reproductive health are often highly sensitive or even taboo to discuss openly, but when positively engaged and provided with evidence-based information, religious and spiritual leaders are often willing to collaborate and to interpret their teachings progressively.

• In the area of RH it is acknowledged that men as spouses or partners are normally the ones who take decisions in the home and who therefore need to be more involved in RH interventions. • In this regard, it is imperative for boys and men to be socialized or re-socialized to take responsibility for the effects of their own sexual Behaviour on their partners’ and children’s health and well-being.

1. Health and social services have to become stigma sensitive 2. Sexual and reproductive health services need to become both truly youth-friendly and girlfriendly – and stigma free. 3. Unpacking the entry points for mainstreaming 4. Protection from discrimination must become a true multisectoral issue 5. Responses to the AIDS epidemic have to ensure that they do not inadvertently promote stigma. Source: IPPF

…seven recommendations 1. New international fora to bring together SRHR and HIV/AIDS 2. Microbicides Advocacy, Research and Action needs to become a stronger part of the global agenda 3. Explicit mention should be made of the continuum of care ( prevention, treatment, care and support) in the Principles

…seven recommendations 4. Addressing – in action- the sexual health needs of men is key 5. GIPA ( Greater Involvement of People Living with HIV/AIDS) 6. Pooling of common messages especially those aimed at young people 7. Joint donor and government advocacy by the two communities

Since ICPD we have made great strides in addressing SRHR in the Region However vast variations in gains exist between countries and also within countries We know that all of us have to work within the country context and will be subject to socioeconomic situations. However as SRHR providers we know our business is saving lives and as such there is no time to waste. We cannot wallow in self pity and admit defeat. We must work like the brave and angry women who in the fifties went to jail just because they advocated for women’s right to Family Planning. The battle is not won.