Introduction

On 20 June 2022, the House of Commons Standing Committee on Foreign Affairs and International Development (the committee) agreed:

That, pursuant to Standing Order 108(2), given recent reports of international backsliding related to women’s sexual and reproductive health and rights, the Standing Committee on Foreign Affairs undertake a comprehensive study on the global access to the full range of health services, including family planning and modern contraception; comprehensive sexuality education; safe and legal abortion and post-abortion care; laws restricting or prohibiting women’s rights to abortion, the medical and socioeconomic importance of maintaining the right to access safe abortion; and prevention and treatment of HIV/AIDS and sexually transmitted infections and what actions Canada can undertake to support women’s sexual and reproductive health and rights globally[.]^[1]

To complete this study, the committee heard from witnesses during five meetings held between 7 December 2022 and 21 March 2023, and it received written submissions. The subject matter that was raised reiterated to the committee the importance of applying the Gender-based Analysis Plus (GBA+) lens to policy work.^[2]

As is clear in the motion that outlined the parameters of the committee’s work, this study was global in scope. In-depth analysis of the situation in individual countries and communities was beyond the scope of this study. Instead, this report provides an overview of key global trends and concerns and puts forward recommendations as to how Canadian policy could be strengthened to help address them.

The report begins with a summary of the international framework—of obligations and commitments—that has been established in relation to sexual and reproductive health. Based on the testimony the committee received, the report then considers whether there has been a global trend of “backsliding” on women’s rights. Moving to the sections that address the design, delivery, and direction of international assistance, the report reiterates the principle of “leaving no one behind,” and explains the importance of context and robust data in this regard. It also considers those aspects of sexual and reproductive health and rights that are considered “neglected,” of which two, in particular, were emphasized by witnesses: comprehensive sexuality education, especially for adolescents, and access to safe abortion services. After examining these “neglected” areas, the report considers the role of local activism and partnerships in the advancement of sexual and reproductive health and rights. It concludes with observations about the linkages between these efforts and Canada’s broader foreign policy.

The International Framework

To contextualize witness testimony, this report begins by explaining why the committee’s study topic, which focused on the health of women and girls around the world, is a matter of human rights. According to the office of the United Nations (UN) High Commissioner for Human Rights,

Women’s sexual and reproductive health is related to multiple human rights, including the right to life, the right to be free from torture, the right to health, the right to privacy, the right to education, and the prohibition of discrimination. The Committee on Economic, Social and Cultural Rights (CESCR) and the Committee on the Elimination of Discrimination against Women (CEDAW) have both clearly indicated that women’s right to health includes their sexual and reproductive health.^[3]

The work of these bodies has been reinforced by international political agreements. The Programme of Action adopted by 179 governments at the International Conference on Population and Development, held in Cairo in 1994, affirmed sexual and reproductive health as a human right, and linked the empowerment of women and girls to the well-being of individuals, families, and societies.^[4] The term “reproductive health,” the participants to the Cairo conference agreed, “implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.”^[5] Furthermore, the Programme of Action established that reproductive rights “rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.”^[6] In practice, as the United Nations Population Fund explained, these principles mean that, “Whenever a woman is denied the power to make her own decisions about whether, when or how often to become pregnant, her internationally recognized human rights are violated.”^[7]

In 1995, the Beijing Declaration and Platform for Action reinforced the principles agreed in Cairo and explicitly enshrined women’s rights as human rights. In creating an agenda for women’s empowerment, representatives of 189 governments^[8] used that lens to address poverty, education, health, violence, and armed conflict, and to examine economic, social, and political power and decision-making, as well as the institutional structures underpinning them. The Beijing Platform for Action also contains a dedicated chapter on girls. The participants affirmed that women’s human rights “include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence.”^[9]

Unrealized Goals

Further to the Millennium Declaration they adopted, the international community agreed in 2000 that there was a clear need to improve maternal health, with one of the targets established to organize their efforts—as of 2007—being the achievement of universal access to reproductive health.^[10] These targets were carried forward and expanded on by the Sustainable Development Goals (SDGs), which address the health, well-being, empowerment, and rights of women and girls.

The SDG targets are supposed to be met by 2030. However, indicators reveal that there are still significant gaps and disparities in SDG attainment, both within and among countries.^[11] SDG 3 seeks a global maternal mortality ratio of fewer than 70 maternal deaths per 100,000 live births.^[12] While the proportion of births worldwide that were assisted by skilled health professionals has increased, the maternal mortality ratio was still 223 in 2020, resulting in an estimated 287,000 maternal deaths. To put that figure in context, it corresponds “to almost 800 maternal deaths every day, and approximately one maternal death every two minutes globally.”^[13] Sub-Saharan Africa accounted for approximately 70% of those maternal deaths in 2020, while Central and Southern Asia accounted for almost 17%.^[14] Between 2000 and 2020, the global maternal mortality ratio is estimated to have fallen by 34.3%.^[15] Nevertheless, the data suggest that progress has stalled—that “almost all the progress achieved during the 2000–2020 period had occurred by 2015.”^[16]

Beyond these “alarming” trends in maternal mortality,^[17] the committee was provided with additional statistics that revealed the challenges that are negatively affecting the health of women and girls and the realization of their rights. These statistics relate to other aspects of the SDGs, such as the commitment to ensure universal access to sexual and reproductive health care services, including for family planning, information and education, as well as universal access to sexual and reproductive health and reproductive rights, as agreed in the outcome documents from the 1994 and 1995 conferences in Cairo and Beijing and their review conferences.^[18]

The data the World Health Organization collects on sexual and reproductive health “consistently point to deep gaps in rights and justice, gender equality, human dignity and broader social well-being.”^[19] For example, “43% of women (15–49 years) report lack of agency in decisions on sexual relations, use of contraceptives and health care.”^[20] Given that the United Nations only collects this data for women who are married or in a union, the committee was informed that the “real numbers are much higher.”^[21]

The committee also heard that many women and girls are facing heightened vulnerabilities because of harmful norms and practices that are undermining their “human rights, their bodily autonomy and their access to life-giving health care.”^[22] In support of this observation, Dr. Natalia Kanem, Under-Secretary-General of the United Nations and Executive Director, United Nations Population Fund, conveyed that,

One in three women experiences physical or sexual violence in her lifetime. One in five girls is married or in a union before the age of 18. More than four million girls are at risk of female genital mutilation this year.^[23]

Changing these norms and practices, Dr. Kanem said, “will require partnerships, first and foremost with communities, with civil society organizations, with traditional and religious leaders and, critically, with men and boys.”^[24]

The Comprehensive Approach to Sexual and Reproductive Health and Rights

Canada has prioritized the advancement of women’s health for many years, including with its mobilization of funding through the Muskoka Initiative on Maternal, Newborn and Child Health, which was launched in 2010. It was then renewed until 2020 and also expanded on in 2017 to explicitly include sexual and reproductive health and rights (SRHR).^[25] Global Affairs Canada informed the committee that, in addition to Canada’s $2.85 billion in funding,^[26] the Muskoka Initiative “leveraged over $9.6 billion U.S. in new commitments from other countries.”^[27] Julia Anderson, Chief Executive Officer, Canadian Partnership for Women and Children’s Health, told the committee that the Muskoka Initiative also “moved the needle significantly” because it included a clear accountability framework, as well as “a diplomatic push and effort to ensure that these two elements of the then millennium development goals that had been largely forgotten in maternal health and newborn health would be engaged in.”^[28]

In 2017, the Government of Canada adopted a Feminist International Assistance Policy. According to departmental officials, with the introduction of this policy, the government built on the foundation that had been laid with the Muskoka Initiative. Support for maternal, newborn and child health was maintained, but the government also “stepped up its investments in sexual and reproductive health and rights, recognizing that promoting rights-based, open and inclusive societies is an effective way to save lives and to foster prosperity, peace and sustainability.”^[29]

In 2019, the Government of Canada committed to increasing its funding in support of the health and rights of women and girls to an average of $1.4 billion annually by 2023–2024, a level that it promised to sustain until 2030,^[30] and which officials described as “unprecedented in its scope and length for Global Affairs Canada.”^[31] The government further committed to devoting $700 million of this annual funding to the promotion of SRHR, with a focus on what the government determined to be four “neglected” areas. These areas, which “were identified through extensive consultations with Canadian and international experts and civil society organizations,”^[32] are the following: family planning and contraception; safe and legal abortion services and post-abortion care; comprehensive sexuality education; and SRHR advocacy.^[33] Therefore, according to departmental officials, the 2019 commitment was not only large-scale and long-term, but also reflected the government’s shift toward a “comprehensive approach” to SRHR.^[34]

Dr. Elizabeth Sully, Principal Research Scientist, Guttmacher Institute, characterized Canada’s commitment to SRHR as “historic.”^[35] Kelly Bowden, Director, Policy, Action Canada for Sexual Health and Rights, similarly believes that Canada’s approach is “critical” and “unique” given the limited funding that is being provided by other donors in the four neglected areas and the need for global leadership.^[36] Canada’s commitment, she said, can show that it “is stepping up where the world is falling short—by emphasizing the fundamental importance of a rights-based approach to sexual health and investing where the need is greatest.”^[37]

The attainment of SRHR has been linked with the advancement of development goals, gender equality, and economic prosperity.^[38] According to Global Affairs Canada, this link was reinforced during the consultations the department held with Canadian and international experts and partners as part of the development of its Feminist International Assistance Policy, and it was also clear from the “scientific and programmatic evidence outlined in the 2018 Guttmacher-Lancet Commission as well as other studies.”^[39] This evidence has informed the government’s policy and the programs it has been undertaking since.^[40]

The Guttmacher-Lancet Commission’s report proposed “a new, comprehensive definition of SRHR that builds on various international and regional agreements, as well as technical reports and guidelines.”^[41] The definition is predicated on the understanding that everyone has “a right to make decisions governing their bodies and to access services that support that right.”^[42] Furthermore, it underlines that health services, information and education related to all aspects of sexuality, sexual experiences, and reproduction should reflect public health and human rights standards.^[43]

This evidence was summarized for the committee by the Guttmacher Institute. Data gathered through decades of research, Dr. Sully stated, “clearly shows that investing in a comprehensive package of sexual and reproductive health services is a smart and cost-savings investment that protects health and saves lives.”^[44] As Dr. Sully explained, it also benefits societies. Making this point, she said:

Investing in a comprehensive package of services can result in substantial gains. For example, if all women in low- and middle-income countries wanting to avoid a pregnancy were to use modern contraception, and all pregnant women and their newborns were to receive care at international standards, we would see a two-thirds decline in unintended pregnancies, unsafe abortions, and maternal and newborn deaths, and an 88% drop in HIV infections among babies six weeks and younger.^[45]

The numbers can also be framed another way, to show the consequences of unavailable or inaccessible services. As one example, Julia Anderson told the committee that “a 12% average decline in access to modern contraception would result in an additional 734,000 unintended pregnancies.”^[46] For another, she indicated that a “23% shift from safe to unsafe abortions will lead to an additional 491,000 unsafe abortions.”^[47]

The committee also heard that, by improving health outcomes for women and girls, the gains from investment in a comprehensive package of SRHR services lessen the burden on healthcare systems. Dr. Sully informed the committee that, “[e]very additional dollar that’s invested in modern contraceptive services would save three dollars on pregnancy-related and newborn care through preventing unintended pregnancies.”^[48]

Attainment of SRHR can have long-term implications. Reflecting on the stories she has heard while leading a partnership that brings together more than 100 organizations, private sector entities, research institutes, and civil society organizations based in Canada, Ms. Anderson said one consistent theme can be identified.

That theme is choice—choice about when, with whom and whether to have children, and how many. This is not just a choice about today. It is an intergenerational choice about the future for yourself and your ability to attain education, a livelihood, employment and economic security for yourself and your family. It’s a choice about how you want to build your community. These are choices women are making across all areas of this globe, and they are absolutely critical. In fact, they touch on every aspect of international development.^[49]

Several witnesses drew attention to the fact that most maternal death is preventable. Expanding on this point, Global Affairs Canada observed that, “Women are dying unnecessarily because they can’t get access to basic, essential health services.”^[50] The government’s approach to SRHR is informed by a desire to address this reality and, more broadly, by its support for “the goal of ensuring that every pregnancy is wanted, that every birth is safe and that every girl and every woman is treated with dignity and respect.”^[51]

Further to this goal, and recognizing that sexual and reproductive rights are integral to the advancement of sexual and reproductive health, the committee recommends:

Recommendation 1

That the Government of Canada continue to invest in a comprehensive approach to sexual and reproductive health and rights globally.

The Risk of Backsliding

Further to the study motion it adopted, the committee sought to determine whether there has been backsliding, globally, in relation to SRHR. Some testimony suggested a mixed picture, with setbacks occurring in certain countries, while restrictions on sexual and reproductive health services and the right to access these services have lessened elsewhere. Other testimony pointed more definitively to backsliding, which—these witnesses argued—is the result of an organized movement—or pushback—against women’s rights.

Dr. Sully conveyed the Guttmacher Institute’s assessment that the global situation with respect to SRHR has reached a “critical juncture.”^[52] While important progress has been made over the last few decades, she said, “as of 2019 there were 218 million women in low- and middle-income countries with an unmet need for modern contraceptive methods.”^[53] The result, annually, is 111 million unintended pregnancies and 35 million unsafe abortions.^[54] What is more, Dr. Sully warned of the “risk of backsliding on the progress that we’ve achieved, with a global opposition to SRHR that’s emboldened by the recent overturning of [Roe v. Wade] in the United States.”^[55] At the same time, however, she suggested that the United States “has become a global outlier by eliminating the right to abortion.”^[56] This development, she said, stands “in stark contrast to decades of progress on abortion rights, with the global trend towards liberalization of abortion laws.”^[57] Further to this point, Dr. Sully noted that—since 1994—the legal grounds for abortion have been expanded in almost 60 countries.^[58]

Global Affairs Canada expressed a similar view. While recognizing that backsliding has occurred in “a number of countries,” the department noted that “many countries have moved to liberalize their laws and provide a more supportive and evidence-driven approach.”^[59] Benin, Argentina, Colombia, the Democratic Republic of the Congo, and Mexico were cited as examples of countries that have increased “the scope of their abortion laws.”^[60]

On the other hand, Global Affairs Canada noted that, since taking power in 2021, “the Taliban have institutionalized large-scale and systemic repression of women and girls that threatens to reverse the Women, Peace and Security gains made over the previous twenty years,” which has hindered Canada’s ability to respond.[61]

Lauren Ravon, Executive Director, Oxfam Canada, indicated that, to some extent, the strongest backlash is being seen in countries “where feminist movements have been built up and supported and have been making progress on women’s rights.”^[62] From her perspective, “the emboldening of anti-rights, anti-choice actors” since the reversal of Roe v. Wade in the United States is producing “a trickle effect across the world in terms of pushing back on some hard-won gains.”^[63]

Kelly Bowden characterized the situation as a continual “push-and-pull of progress versus risk.”^[64] Yet, she also brought to the committee’s attention reports produced by the Association for Women’s Rights in Development and the European Parliamentary Forum for Sexual and Reproductive Rights, which have tracked “financial investments that are going into organizations that are doing active work, either legal work or public advocacy, to undermine access to these rights.”^[65] In Ms. Bowden’s view, the data “shows the increase in those financial flows, which leads us to be concerned that there is a growing organized movement in opposition to these rights.”^[66]

The International Planned Parenthood Federation believes that attempts around the world “to roll back hard-won reproductive rights and gender equality” reflect “a bold, organized opposition.”^[67] The Federation suggested that this opposition, “combined with political polarization and the rise of extremism in many countries, threatens sexual and reproductive justice, human rights and gender equality.”^[68]

Beth Woroniuk, Vice-President, Policy, Equality Fund, spoke from the perspective of an organization that channels funding to more than 300 women’s rights organizations and LGBTQI groups in some 85 countries. While acknowledging the important gains that have been made, primarily in Latin America, she told the committee that,

We are seeing well-funded and organized attacks on advocates and coordinated efforts to limit and restrict comprehensive sexuality education and abortion rights. This is often referred to as the “anti-gender” movement, and it is intimately linked to efforts to restrict LGBTQI rights and generally roll back advances on women’s rights.^[69]

In the face of these attacks, Ms. Woroniuk, said, women’s rights organizations are trying to “hold the line.”^[70]

Poland was presented to the committee as a case study of SRHR backsliding. Since 1993, legal access to abortion services in Poland had been based on three grounds: where the pregnant woman’s life is at risk; when the pregnancy is the result of rape or incest; or, when the pregnancy involves severe or fatal fetal impairments. In 2020, the Constitutional Tribunal, whose independence has been the subject of concern, ruled that the third exception was unconstitutional. Krystyna Kacpura, President, Foundation for Women and Family Planning, told the committee that the tribunal’s decision—which she said contravenes Poland’s obligations under international human rights treaties and the European Convention on Human Rights—“has severely rolled back the already severely limited protection for women’s access to legal abortion in Poland, and resulted in a near total ban on abortion.”^[71] There is also limited access to contraception in Poland, particularly emergency contraception. According to Ms. Kacpura, this situation cannot be understood in isolation from “the impact of the transnational antigender movement, which is quite powerful in Poland and operates in synergy with the current ultra-conservative government.”^[72]

Leaving No One Behind

The international development agenda is anchored by the core principle of “leaving no one behind.” This principle represents a shift away from evaluating progress based solely on aggregate statistics. It is meant to focus efforts on ensuring that development gains are reaching marginalized communities and vulnerable populations.

Further to this principle, testimony emphasized that SRHR must be integrated across health systems and made available to the population where and when needed. At the same time, testimony also called for SRHR to be embedded in international responses to conflicts and crises. Whether it is in this first set of situations, where health systems need to be strengthened, or the second, where services need to be provided when systems have been disrupted, programming is made more effective when it is informed by data. Nevertheless, the committee learned that the data gaps remain significant.

The International Planned Parenthood Federation argued that the principle of leaving no one behind “not only entails reaching the poorest of the poor but requires combating discrimination and inequalities and their root causes.”^[73] In addition to proactively ensuring equitable access to services for the most vulnerable, the Federation believes that women and girls should have access to a “comprehensive package of SRHR services and care” and that there should be investments in “a continuum of care on reproductive, maternal and newborn health.”^[74] According to the Federation, interventions that have shown they can improve access for under-served groups include mobile outreach, postpartum family planning, and youth-friendly programming.^[75]

Humanity & Inclusion Canada also highlighted the need for programming that targets disability-inclusive SRHR, noting the minimal funding that is allocated for that purpose now.[76] For example, aid projects targeting disability inclusion totalled US$3.2 billion between 2014 and 2018, representing less than 0.5% of all international aid. Humanity & Inclusion Canada pointed out that, in 2022 at the World Disability Summit, Canada had reiterated its commitment to provide greater assistance to persons with disabilities in developing countries, a commitment set out in the mandate letter to the Minister of International Development.[77]

The committee heard that investment in the frontline workforce can expand health service delivery and ensure those services are reaching people in need. Dr. Kanem remarked that the education and deployment of midwives is one of the “most cost-effective ways to prevent maternal deaths.”^[78] Nevertheless, she said, while midwives “can deliver 90% of all essential sexual, reproductive, maternal and newborn health services,” there is currently a “global shortage of 900,000 midwives.”^[79] Julia Anderson agreed that “investment in community health care workers, in trained midwives, is the most effective intervention that Canada could support in all its development projects, especially when it comes to women’s and children’s health.”^[80] Connecting this point to inclusion, she also observed that trained midwives “can be major interlocutors with communities and community leaders.”^[81]

Efforts to strengthen health systems and respond to humanitarian crises are usually thought of as distinct activities, implicating development assistance in the first set of circumstances and humanitarian assistance in the second. Nevertheless, Kelly Bowden explained why these efforts should not be considered in isolation from one another. She said:

Unless SRHR is fully integrated into health systems as a foundational aspect of health care, it is easily deprioritized when the system comes under stress or strain. We see this in fragile states and humanitarian settings, and we saw this around the world throughout the COVID-19 pandemic. Maternal mortality and gender-based violence increased and rollbacks to contraception and other SRH services occurred.^[82]

When Ms. Bowden was asked to recommend steps that could be taken to ensure all women have access to the full range of sexual and reproductive health services, including in conflict settings, she reiterated the importance of strengthening health systems through an integrated and comprehensive approach. This integration must happen, she said, at the same time as there is “stand-alone programming to help ensure access to these services in times of great need.”^[83]

Referencing such times—or crises—Dr. Alvaro Bermejo, Director General, International Planned Parenthood Federation, commented that, “There is no doubt in our minds, and there shouldn’t be doubt in anybody’s mind, that sexual and reproductive health services are life-saving services that need to be provided in conflict situations.”^[84] Nevertheless, the committee heard that these services are underfunded in humanitarian settings or are not being treated as a core aspect of humanitarian action, unlike water, sanitation, and infrastructure.^[85]

It is broadly understood that sexual and reproductive health needs are exacerbated during humanitarian crises, when the risk of sexual violence is heightened and access to health facilities and services is interrupted. Despite these realities, and the recognition that sexual and reproductive health services should be part of primary care, Dr. Sully observed that they “are often forgotten and not included as part of the humanitarian response.”^[86] That is happening, she said, even though the Inter-Agency Working Group on Reproductive Health in Crises—a coalition of UN agencies, governments, international and national non-governmental organizations, and others^[87]—has developed a Minimum Initial Service Package. This package has been characterized as a “set of minimum lifesaving SRH interventions,” which reflect “an international standard of care that should be implemented at the onset of every emergency.”^[88]

Echoing this assessment, Ms. Anderson indicated that her organization has “made a strong case” that the Government of Canada should advocate for SRHR to be thought of not as “additional” but as “critical and central” to the essential package of interventions in humanitarian crises.^[89] Similarly arguing for SRHR to be “a core programming area in Canada’s responses to crises,” Beth Woroniuk reminded the committee that the government is in the process of developing Canada’s third national action plan on the women, peace and security agenda, and updating its gender-responsive humanitarian assistance policy. She believes that “[r]esources for SRHR, especially the neglected areas, should be key elements in these two plans.”^[90]

While the risks facing women and girls in conflict settings are often described in general terms, they were put into sharp focus by Lesia Vasylenko, a Member of Parliament from Ukraine, who described in detail how Russia has used sexual violence as a weapon against the Ukrainian people. Recounting what transpired in February and March 2022, when the region around Kyiv was being occupied by Russian forces, Ms. Vasylenko said that “commands were given to military units to spare no civilians and intimidate the civilian population in all ways possible.”^[91] The horrific stories that have since emerged from survivors include the following:

Women and young girls were kept captive, sometimes in the basements of their own homes, where they were subjected to hearing the conversations of the soldiers holding them hostage; they would be rape victims and would need to choose, from among themselves, who would be raped that night.^[92]

The war’s victims of sexual violence range in age from 4 to 80 years old.^[93] The basic idea behind Russia’s tactic, Ms. Vasylenko said, is “to intimidate the population, to inflict fear on the population and to demoralize the civilian population in their resilience and in their resistance.”^[94] She also recognized that, even in Ukraine, where survivors are being actively supported by a fully functioning government and its international partners, the extent of the sexual violence that has been perpetrated is not known because of stigmatization, which suppresses reporting.^[95]

There are many other humanitarian settings around the world where women are facing heightened vulnerabilities because of violence and dislocation. Dr. Sully acknowledged to the committee that her organization—the Guttmacher Institute—does not have robust data on fragile contexts writ-large, let alone data that could shed light on the situation facing specific populations, including adolescent girls. More funding needs to be invested in data, Dr. Sully said, “to generate evidence to really understand those needs.”^[96] Even so, she indicated that some big pieces of the picture are already clear.

What we do know is that, when adolescents and all women in these contexts have unintended pregnancies and they are unable to access safe abortion services and they go and have unsafe abortions, they are having the least-safe abortions. Unsafe abortion is a very broad category, but there are extremely dangerous unsafe abortions that are part of that category. When we’ve done research in refugee camps and in humanitarian settings, we’ve seen that those in those camps have worse and more severe complications from unsafe abortions compared to people in the surrounding communities. They aren’t even able to access the same services as those in the same geographic area.^[97]

These severe complications, Dr. Sully noted, have a long-term impact on the health of the women who experience them.

While the data gaps are particularly acute in humanitarian settings, the problem is more generalized. Even in Canada, a high-income country, the understanding of vulnerabilities in relation to SRHR remains incomplete. Dr. Diane Francoeur, Chief Executive Officer, Society of Obstetricians and Gynaecologists of Canada, told the committee that,

Canada lacks reliable and accurate data on the health of its women when it comes to monitoring indicators and producing reports to guide investments and decision-making. We see some aberrations on the ground, such as the fact that women of colour, indigenous women and new Canadians appear to be more likely to die during childbirth in Canada. However, we have no data to support these observations, as these data are not measured or reported.^[98]

Elaborating on this point, Dr. Jocelynn Cook, Chief Scientific Officer, Society of Obstetricians and Gynaecologists of Canada, explained how data could be used to make targeted interventions in health systems, with the view to improving health outcomes. She said:

If we understand what’s happening from a true evidence and data perspective, then we can start to plan and anticipate and identify where we need more education for the public—in what languages, for example—and more education for health care providers who are dealing with very different circumstances and contexts and even patient populations. Then we can work together and see where we can have points of intervention and prevention.^[99]

The importance of building an evidence base was underlined by the World Health Organization. It wrote to the committee that, “Investing in research and evidence-generation on sexual and reproductive health, its determinants and pathways is an investment in women’s sexual and reproductive rights.”^[100] That is so because it is by “building the best evidence and recommendations based on rigorous research, and clinical and community interventions [that] human rights-based approaches to sexual and reproductive health can be supported, and social norms, values and systems detrimental to health can be challenged.”^[101]

Based on the information it received about health systems and crises, and in support of the principle of leaving no one behind, the committee recommends:

Recommendation 2

That, as part of its international assistance for the strengthening of health systems, the Government of Canada promote the integration of sexual and reproductive health as a core component of primary health care, and that it promote equality of access to those health services.

Recommendation 3

That the Government of Canada provide funding for the realization of minimum standards of sexual and reproductive health as part of its immediate and ongoing humanitarian assistance, and that it also use its role within the international humanitarian system to advocate for sexual and reproductive health and rights to be prioritized in every humanitarian response.

Recommendation 4

That the Government of Canada’s next national action plan on women, peace and security and its gender-responsive humanitarian assistance policy reflect Canada’s prioritization of sexual and reproductive health and rights.

Recommendation 5

That the Government of Canada support and advocate with like-minded donor and ODA eligible countries to strengthen the collection and analysis of comprehensive and disaggregated data on sexual and reproductive health and rights, including data about women and girls in situations of armed conflict and other humanitarian crises.

Recommendation 6

That the Government of Canada increase funding for programming that targets disability-inclusive sexual and reproductive health and rights.

The Neglected Areas

As was noted at the beginning of this report, the Government of Canada has committed to allocating $700 million, annually, from its overall funding for women’s health and rights in support of comprehensive SRHR and to focusing this programming on four “neglected” areas. Again, those are: family planning and contraception; safe and legal abortion services and post-abortion care; comprehensive sexuality education; and SRHR advocacy.

Canada contributed $489 million in support of SRHR in 2020–2021,^[102] but Global Affairs Canada expects “to hit that target of $700 million” for the 2023–2024 fiscal year.^[103] Nevertheless, Béatrice Vaugrante, Executive Director, Oxfam-Québec and Oxfam Canada, believes that the government will have to “aggressively scale up funding in these areas to meet the target by the 2024 deadline.”^[104] Julia Anderson similarly suggested that “consistent, stable and predictable increases” to Canada’s funding are needed to meet the target by the end of the year.[105]

Testimony also raised concerns about the amount that has been invested in the four neglected areas so far. In 2020–2021, that figure was close to $104 million of the $489 million in total SRHR funding.^[106] In Lauren Ravon’s view, there is “clearly an underinvestment” in these four areas.^[107] What is more, the committee heard that the bulk of this funding was for family planning and SRHR advocacy, while a “very minor amount”^[108] was directed to comprehensive sexuality education ($5.4 million) and safe abortion services ($1.9 million).^[109] Kelly Bowden characterized these as the “neglected among the neglected” areas and as requiring “further attention.”^[110] They are addressed in detail in the next subsection of this report.

Recommendation 7

That the Government of Canada meet its commitment to spend at least $700 million on the sexual and reproductive health and rights of women globally by the end of fiscal year 2023–2024, and that it sustain this spending level, annually, until 2030.

Adolescents

While Global Affairs Canada has not designated adolescents, themselves, as a “neglected” part of SRHR, testimony drew the committee’s attention to concerning health indicators for adolescent girls and suggested the need for targeted support. It also became clear that the four neglected areas that have been identified, including comprehensive sexuality education, are connected to the rights and health of adolescents.

The central challenge was framed for the committee by Global Affairs Canada, which conveyed that,

too often around the world youth and adolescents in developing countries don’t receive adequate information both on their own rights, the right to bodily autonomy in particular, but also on sexuality and reproductive functions and services that they should have access to.^[111]

To address this issue, the department indicated that programs can support formal curricula in schools, but that information can also be made available through social services that adolescents can use “to properly exercise bodily autonomy.”^[112] According to the department, this comprehensive approach to SRHR “follows best practices as identified by the World Health Organization.”^[113]

When asked whether it is equally important to invest in awareness and contraception, in addition to providing resources for safe abortion services, the department indicated that “it starts with comprehensive sexuality education so that adolescents have access to clear and evidence-based information about the services they can access.”^[114] The International Planned Parenthood Federation similarly characterized this type of education as “a critical enabler for young people to realise and claim their rights, and to challenge harmful norms, for girls and women, and for boys and men.”^[115] A different perspective was put forward by Lucy Akello, a Member of Parliament from the Republic of Uganda, who said that the parents she represents see comprehensive sexuality education “as an assault [on] the health and innocence of children.”^[116]

More generally, the committee heard that when adolescents do not have access to adequate health services and education, and when their rights are not being protected, the consequences can be dire. Dr. Kanem stated:

[W]e know that nearly one-third of women in low- and middle-income countries begin child-bearing in their adolescence, age 19 and younger. This has implications in terms of consent and in terms of how a girl navigates her adolescence safely, often in the absence of comprehensive sexuality education that would be protective to her. Every year, there are an estimated 21 million pregnancies among girls aged 15 to 19 in low- and middle-income countries, nearly half of these being unintended. A significant number end up in abortion, and the majority of those abortions are in unsafe conditions.^[117]

In a separate exchange during questioning, Dr. Kanem referenced the UN Population Fund’s most recent State of World Population report, which dealt with unintended pregnancy and “covered the circumstances under which lack of access can be lethal, literally, in the sense that women lose their lives.”^[118] Dr. Kanem remarked that “the woman who dies during many of these occurrences is not a woman at all. She is an adolescent girl who, whether through ignorance or through lack of access, or sometimes through coercion, became pregnant and there was no support.”^[119]

Adolescent women are, thus, facing multifaceted SRHR challenges, relating to access, information, and rights. Causes and consequences—including poor educational outcomes—are interlinked.^[120] At the same time, the committee was informed that adolescents are also facing “unique and disproportionate barriers.”^[121] The inability to pay for health services or to travel to health service points are examples. Some barriers result from restrictions, including laws and policies “in many countries” that “forbid the provision of various forms of healthcare services (e.g. contraception) to adolescents or to those who are unmarried.”^[122]

Adolescents are also facing disproportionate risks in relation to sexually transmitted infections, the prevention of which they are “less well prepared” to navigate in the absence of comprehensive sexuality education.^[123] The committee was informed that adolescent girls in Sub-Saharan Africa are the only population group that is not seeing the expected reduction in HIV infections, a situation that is, according to Global Affairs Canada, “intimately tied to broader questions of bodily autonomy and gender equality.”^[124]

Recommendation 8

That the Government of Canada prioritize adolescents in its programming focused on sexual and reproductive health and rights, including by supporting their access to comprehensive health services, information and education, and initiatives that are proven to be effective in preventing sexually transmitted infections.

Safe Abortion Services

The committee was informed that at least 40,000 women are dying, annually, around the world because of unsafe abortion, a figure that is “certainly under-reported” and “likely much higher.”^[125] These fatalities account for an estimated 13% of all maternal deaths[126] and the risk is disproportionately high for women living in certain regions.^[127] Some 62% of all abortion-related deaths are being recorded in Africa.^[128] That region—along with Asia and Latin America—“have some of the most restrictive abortion laws in the world and account for 97% of all unsafe pregnancy terminations.”[129]

Added to this is the new reality brought on by the COVID‑19 pandemic. The brief from the Canadian Partnership for Women and Children’s Health, referring to a report from the African Population Health Centre, noted that in five African countries (Burkina Faso, Ethiopia, Kenya, Malawi and Uganda) the pandemic had forced women and girls to travel to more distant health facilities to access SRHR services.[130]

The primary driver of fatalities connected to unsafe abortion is “a lack of access to effective reproductive health services, including safe and legal abortion services and postabortion care at a significant scale to meet the need.”^[131] One service that was highlighted in this regard is contraception. Dr. Sully told the committee that,

The countries that have the highest rates of unintended pregnancy are often also those that restrict contraceptive access and have higher rates of abortion. The restriction of abortion often goes hand in hand with lack of access to family planning services.^[132]

Consequently, Dr. Sully recommended that those services be made available.^[133] At the same time, she observed that contraceptive programming is not only about overcoming issues with access, nor is it solely a question of available financing. Dr. Sully stressed that women “always need to have free and informed choice on a range of methods available at a place near them, in their communities.”^[134] It is, therefore, also a matter of information and education.

Multiple witnesses stressed to the committee that legal restrictions on abortion do not stop abortions from happening. Instead, these restrictions increase the proportion of abortions that are unsafe.^[135] For example, after emphasizing that her organization—the Canadian Partnership for Women and Children’s Health—takes “an evidence-based approach” to these issues, Julia Anderson stated the following: “The evidence is unanimous and clear that the restriction of abortion does not stop abortion; it only increases unsafe abortion, and it loses women’s lives.”^[136] In its submission to the committee, the World Health Organization conveyed these facts: in countries where abortion is allowed on request, “nearly 87% of abortion[s] are safe; in countries that prohibit abortion or allow it only to save the life of the woman or protect her physical health, only 25% of abortions are safe.”^[137] One witness, Dr. Nkechi Asogwa, characterized the evidence indicating that abortion bans do not stop abortion—and that legalizing abortion reduces maternal mortality—as a “myth.”^[138]

Briefing the committee on the situation in Poland, where—as previously noted—the legal parameters for accessing abortion have been narrowed, Krystyna Kacpura indicated that there are still approximately 120,000 abortions annually, “which are mostly done at home with pills” (i.e., through medical abortion).^[139] Some are being done in neighbouring countries of the European Union.^[140] This information underscored the equity issues that are arising from restrictions on abortion access. Ms. Kacpura commented that,

We are a democratic country in the centre of Europe, so it’s not difficult to get access to safe abortion services, but you have to know the language, you have to live in a big city and you have to have access to the Internet. You have to have money for this.^[141]

What the situation in Poland amounts to, in the view of Ms. Kacpura, is “reproductive injustice.”^[142] That is because the legal restrictions are affecting “the poorest underserved people with no privilege, living in small towns and villages, and with no money[.]”^[143]

Similar inequities exist elsewhere, even in the United States.^[144] Summarizing what has been seen by Oxfam America, which is working with organizations across the United States, Lauren Ravon indicated that,

the biggest impact has been on marginalized communities. Black women in particular have seen a harder access to abortion. There’s a direct correlation between poverty and being able to fly, take a train or take a car to get to safe abortion.

Communities that are in poverty have less access to take the three days off work. That would mean getting into the car, driving across the border to another state and having access to health care to begin with. Poverty is really the intersecting factor here, so it’s not only a crackdown on women; it’s a crackdown on poor people.^[145]

Despite what is known about the consequences of unsafe abortion, which concerns the health, rights and dignity of women, Ms. Ravon drew attention to the fact that, in the first year of reporting on its SRHR commitment, the Government of Canada allocated less than $2 million in support of safe abortion services.^[146] “You can imagine that, if you trickle that around the world, it’s not a whole lot of money,” she said. Consequently, her organization—Oxfam Canada—would like to see Canada “ramping up” in this area where most donors are not investing.^[147] Kelly Bowden similarly remarked that, while the Government of Canada is “naming” access to safe abortion services “as a part of the comprehensive package of care, we are not putting the money in this area just yet.”^[148]

Ms. Ravon also said that post-abortion care should not be forgotten. She told the committee:

I’ve worked in countries, like Kenya, where the emergency rooms are flooded with women who have had unsafe abortions, so there is a huge weight on the public health care system and on hospitals. Also, these are women whose futures are compromised. They might not be able to have children later when they want or have health problems for the rest of their lives, so this is really an area where Canada can be investing.^[149]

On this same issue, Julie Théroux-Séguin, Global Thematic Leader, Women and Girls Rights, Centre for International Studies and Cooperation, observed that “in countries where abortion is illegal, medical staff lack knowledge about postabortion care, even in cases of involuntary termination.” Furthermore, she said, the staff lack “the counselling skills to address women’s needs or the difficulties women may face.”^[150] As a final point, the committee is aware that international guidelines for “comprehensive abortion care” include post-abortion care.^[151]

Recommendation 9

That, as it scales-up its assistance for sexual and reproductive health and rights globally, the Government of Canada ensure it is fully supporting access to modern forms of contraception, safe and legal abortion services, and post-abortion care.

Programming through Partnerships

Some witnesses who appeared before the committee said that national legal frameworks and sovereignty must be respected in relation to SRHR and criticized what they see as the external imposition of agendas. Others told the committee that internationally funded programming is designed and delivered in partnership with local actors, who are the protagonists—rather than the passive recipients—of such efforts, which uphold human rights. These different perspectives are discussed next.

According to Lucy Akello, Member of Parliament from the Republic of Uganda, a 2013 survey indicated that a strong majority of Ghanaians, Ugandans, Kenyans, Nigerians and Tunisians considered abortion “to be morally wrong.”^[152] In reflection of what she characterized as widely held beliefs, almost 80% of African countries have some form of law prohibiting or restricting abortion.^[153] On this same point, Dr. Theresa Okafor, Director, Foundation for African Cultural Heritage, remarked that,

Advocacy to liberalize laws in countries that oppose abortion amounts to undermining the legislative and democratic processes of sovereign states and to subverting the deep values and good cultural traditions of these nations.^[154]

For Dr. Okafor, it “is increasingly clear that foreign funding and the feminist international assistance policy are becoming less about aid, empowerment, health care and poverty reduction, and more about ideological colonization.”^[155]

Dr. Nkechi Asogwa described the circumstances that could be facing a poor woman living in Lagos, Nigeria. She identified nutrition, education, basic antenatal care, skilled birth attendance, and economic empowerment as being higher priorities than what she believes are donor-determined solutions to sexual and reproductive health challenges.^[156]

Dr. Maria Cristina Rodriguez Garcia, Research Consultant, Political Narratives and Women’s Affairs, National Women’s Civic Association, spoke more generally, from the perspective of an organization that has worked on women’s public participation in Mexico. She urged the committee, as it studies sexual and reproductive health and sexuality, to avoid focusing narrowly on access to contraception, and to consider the cultural expectations and emotional pressures women are facing, as well as the importance of healthy relationships.^[157] Referencing the experience of survivors of sexual violence and exploitation, in a country that she later noted has seen “femicides” and narco violence against women,^[158] she also argued that more attention should be paid to “trauma and fragmentation.”^[159]

Other testimony drew attention to the locally led—and, in many cases, grassroots—activism that is pushing for expanded access to health services and the realization of sexual and reproductive rights. Commenting on the situation in Mexico, Lauren Ravon told the committee that “indigenous women led the charge for abortion to be legalized in the poorest provinces of Mexico, with Oaxaca being first.”^[160] This “green wave” was led by indigenous women, she said, “because they know that they are suffering the consequences of unsafe abortion and lack of public services.”^[161] According to Ms. Ravon, this movement was not driven or imposed on Mexican women from the outside. Instead, it was the leadership and mobilization of “grassroots, rural, indigenous women’s movements” which brought about changes in a country that had “very restrictive abortion laws.”^[162]

Dr. Sully of the Guttmacher Institute spoke about the context in Africa. She referenced the Maputo Protocol, which was signed in 2003 and—through its Article 14(2)(c)^[163]—establishes “the legal grounds on which the African Union member states have agreed that they want abortion to be accessible within the African Union.”^[164] Dr. Sully noted that 21 countries have since liberalized “their laws to some extent to meet the Maputo protocol, with seven of those countries going beyond the conditions outlined within that protocol.”^[165] These initiatives, she said, reflect “country-led efforts to protect lives, expand rights and reduce the maternal mortality crisis that is happening across sub-Saharan Africa.”^[166] Furthermore, she noted that these efforts are often being led—within the countries in question—“by politicians, clinicians and bureaucrats who understand the health consequences of unsafe abortion.”^[167] Referencing the case of Benin, the most recent country to liberalize its law, Dr. Sully highlighted the role played by “two members of Parliament who were OB/GYNs and who saw first-hand the consequences of unsafe abortion.”^[168]

Several witnesses emphasized that their work on SRHR is designed to support women and enable them to make their own decisions. Ms. Ravon underlined this point, as follows:

When we talk about what aid Canada is providing, we’re providing aid to countries that are independent, that have their own social movements and have a variety of perspectives within their own community. We’re not saying that every single person in any of these countries wants access to these services. What we’re saying is that there is a demand for it. There is an unmet need, whether it’s for family planning, contraception or safe abortion, and those who want it should be able to have access to it.^[169]

The objective, Ms. Ravon said, is not to influence culture, but to bring what is inevitable—unintended pregnancy—out of the shadows so that women in every country, without exception, have access to safe services and medical options.^[170]

Testimony also indicated that SRHR programming is being delivered through partnerships. Global Affairs Canada told the committee that it “only provides international assistance for global health and SRHR that supports local priorities.”^[171] Furthermore, the department wants to ensure “that those local priorities are shaped not just by national governments but also by subnational and community voices, including youth.”^[172] As one of the conduits of this international assistance, Oxfam Canada emphasized that it partners with local women’s rights organizations who are “the ones leading the agenda” and working “to support their communities.”^[173]

On the specific issue of support for family planning, the United Nations Population Fund emphasized its voluntary nature, “precisely because the rights issue comes down to individual choice.”^[174] Dr. Kanem stated firmly that the agency “does not co-operate with, nor do we uphold any coercive practices.”^[175] Two international non-governmental organizations that do provide reproductive health services that include abortion indicated that their member associations work within the full extent of the national legal frameworks of the countries where they are active.^[176]

Given the importance of local partnerships, Mohini Datta-Ray, Executive Director, Planned Parenthood Toronto, believes that Canada could be doing more to build “the feminist organizing that is happening on the ground.”^[177] She said,

I think sometimes, as I’ve seen with witnesses, there’s often a tension, a feeling like there is a western approach or there’s a white saviour mentality. The way we get around that is to build relationships on the ground with feminists who are there in every instance, pushing for their basic human rights and reproductive justice.^[178]

Nevertheless, and despite the “essential role” that they play, Beth Woroniuk informed the committee that women’s rights organizations are “dramatically underfunded.”^[179] In fact, the latest figures from the Development Assistance Committee of the Organisation for Economic Co-operation and Development show that “overall development-assisted funding to women’s rights organizations has actually decreased.”^[180]

Recommendation 10

That the Government of Canada continue to advance sexual and reproductive health and rights around the world through local partnerships, in support of women’s rights and feminist movements, and in accordance with internationally recognized human rights.

Recommendation 11

That the Government of Canada increase the proportion of its international assistance that is being delivered to and through women’s rights organizations, including those working to advance sexual and reproductive health and rights.

Conclusion

Most of the recommendations in this report deal with the international assistance that the Government of Canada provides. Nevertheless, some witnesses urged the committee to avoid taking a siloed approach to women’s health and rights, which—they argued—concern more than development policy.

In her call for there to be a “cohesive strategy around SRHR” that is part of Canada’s broader foreign policy, Julia Anderson told the committee that “investment alone is not enough.”^[181] As Lauren Ravon said, it is “a matter of combining money and voice.”^[182] Set against the risk of “backsliding” on women’s rights that is being seen in countries and international forums, Kelly Bowden argued that Canada “has a huge platform to stand on” because of the investment it has made.^[183] From her perspective, there is “an opportunity that needs to be leveraged in order to take global leadership and work with others to continue to ensure that we make progress on these rights.”^[184] That work, she suggested, must be “integrated into a more fulsome approach through a feminist foreign policy.”^[185] Both the Canadian Partnership for Women and Children’s Health and Action Canada for Sexual Health and Rights want Canada to embrace its leadership role, engaging with G7 countries and other allies to catalyze further global investment in SRHR, especially in the neglected areas.[186]

Echoing the need for Canada to “speak out clearly and consistently in global forums and bilateral discussions,” Beth Woroniuk called for the government’s “long-promised feminist foreign policy” to be released.^[187] Having a clear written document is important, she explained, because “it would set out feminist policy guidance not just for international development, but for trade, immigration, diplomacy and how consulate affairs work.”^[188] In the absence of such a document, she said, “diplomats and aid workers are often not aware of what their responsibilities are, and we’re also not clear globally.”^[189]

While policy documents can have a practical effect, by guiding the Government of Canada’s programs, activities, relationships, and negotiations, regardless of the department—or branch within—that is involved, they can also set a marker, for those beyond Canada. This potential was revealed in the words of Dr. Kanem, who told the committee that Canada’s “leadership is a beacon of hope at a time when push-back on gender equality and women and girls’ rights is intensifying.”^[190]

Recommendation 12

That the Government of Canada use its role in international forums like the G7 to catalyze further investment in sexual and reproductive health and rights programming and to advocate for the prioritization of sexual and reproductive health and rights globally.

Recommendation 13

That the Government of Canada publish its feminist foreign policy in a document that details principles, objectives, and guidelines for policy implementation, and which integrates Canada’s comprehensive approach to sexual and reproductive health and rights.

Recommendation 14

That the Government of Canada actively oppose coercive population control targeting Uyghur women as part of the ongoing Uyghur genocide, and call on governments and international bodies to reject and oppose coercive population policy.