1.1. Contraception: undeniable progress

The Programme of Action aimed to ensure the right to birth control through the development of family planning. The increased use of contraception is clearly a major step forward in terms of sexual and reproductive rights over the past 30 years. Efforts to make the various contraceptive methods more accessible have helped to reduce the number of unplanned pregnancies worldwide considerably, from 79 per 1,000 women aged 15–49 in 1990–1994 to 64 in 2015–2019 [1]. In 2021, of the 1.1 billion women worldwide aged between 15 and 49 who wished to delay or avoid becoming pregnant, 77% used a ‘modern’ method of contraception (the pill, IUD, injectable contraceptive, condom, etc.), and 8% used a ‘traditional’ method, such as withdrawal or periodic abstinence.²

Despite this overall increase, the use of contraception in general and of certain methods in particular appears strongly guided by the recommendations of healthcare staff and by the availability of contraceptives. In addition, while the Programme of Action mentioned the need to ‘emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behaviour, including family planning’, their involvement and the re­sources made available to them remain low. Only female contraceptives, mostly hormone-based (hormonal IUD, implant, patch, and ring), have been developed over the past 30 years, suggesting that contraception remains primarily a female responsibility, contributing to the persistence of gender inequalities regarding sexual behaviours, contraception, and reproduction.

1.2. Abortion: legalized in some countries, restricted in others

The Programme of Action did not recognize abortion as a reproductive right due to strong opposition from conservative quarters. Only access to post-abortion care was guaranteed, i.e. the ability for women to receive care from healthcare services in the event of severe complications following an abortion or miscarriage. When it comes to the legalization of abortion, the situation varies across the globe, and the past 30 years have seen both major steps forward and setbacks in this area. In Latin America, Uruguay (2012), Argentina (2020), Colombia (2022), and Mexico (2023) have legalized abortion after decades of feminist activism. In Europe, Portugal (2007) and Ireland (2018) liberalized their abortion laws, while in Poland (2020) abortion is now almost entirely banned. The right to abortion also came under threat in the United States in 2022, with the Supreme Court’s overturning of the Roe v. Wade decision; this opened the door for each state to authorize or ban abortion and caused a health and humanitarian crisis in certain conservative states.

Over the past 2 years, 14 out of the 50 states have made abortion illegal. In France, in reaction to the rollback of abortion rights in the United States, various parliamentarians called for the right to voluntary termination of pregnancy to be enshrined in the Constitution, which was duly revised to include women’s ‘guaranteed freedom to abort’ in 2024.³

When access to abortion is illegal or highly restricted, people turn towards illegal practices that may threaten their health or life if dangerous methods are used. Unsafe abortions cause between 5% and 13% of maternal deaths across the world each year [2]. But overall, with better access to abortion drugs and more specifically to misoprostol, even clandestine abortions can be self-managed more safely.

1.3. 670,000 children worldwide conceived using assisted reproduction

The past 3 decades have also seen the development of new technologies to help those who cannot conceive spontaneously, generally heterosexual couples but also same-sex couples and single people, across the globe. Where these technologies are available and accessible, they have expanded reproductive options for anyone wanting to become a parent, although success rates remain relatively low. Today, nearly 100 countries have assisted reproductive technology (ART) services, and more than 670,000 children worldwide were conceived using ART in 2018 [3]. The number of people seeking assisted reproduction is rising sharply across the world, leading to an increase in the number of babies born with the help of ART. In Europe in 2018, the proportion of children conceived using in vitro fertilization (IVF) as a percentage of all births ranged from 0.1% in Serbia to 9.3% in Spain, with the rate in France at 2.8% [4]. In the same year, the rates in Latin America varied from 0.04% in Guatemala and Venezuela to 0.9% in Uruguay [5]. However, data on ART are sporadic and non-­standardized, as countries and medical centres do not systematically record their activities in accessible institutional registers.

While ART represents progress in terms of sexual and reproductive rights, access to it is still impacted by significant socio-economic, racial, and gender inequalities [3]. ART is usually performed at private medical centres, where the costs are particularly high. From a legal perspective, access to ART is often reserved for certain populations, such as cisgender people and heterosexual couples. Last, the provision of such medical care may also differ depending on people’s sociodemographic characteristics, particularly their race.

1.4. Continuing efforts to prevent STIs

The Programme of Action included the objective of preventing STIs and the spread of HIV/AIDS, and significant progress has been made over the past 30 years thanks to the combined efforts of patient associations, the medical and research community, activists, and donors. The first effective treatments—antiretrovirals—were developed in 1996 in the wealthiest countries but were not made accessible in low- and middle-income countries until 2004. Many innovations followed during the 2010s, such as medical prevention, universal treatment (i.e. immediately after diagnosis regardless of viral load), and self-testing kits. However, these new tools are not accessible to everyone who needs them. Furthermore, as of 2023, there were still 5.4 million people unknowingly living with HIV.⁴

1.5. Increasing use of self-managed care and telemedicine

Self-managed care (i.e. the ability to prevent health problems or to cope with illness or disability with or without the support of a healthcare provider) is now being promoted by international organizations such as the World Health Organization, to advance universal health coverage and reduce health inequalities. These self-managed interventions include home pregnancy tests, self-sampling kits to screen for STIs such as HIV or papillomavirus, which causes certain cancers, as well as the self-administration of injectable contraceptives, etc. Likewise, the use of telemedicine expanded considerably during the COVID-19 pandemic, allowing continued access to certain types of healthcare, including reproductive healthcare; its use is expected to increase further over the long-term in order to eliminate medical deserts and serve previously ­excluded populations. In some countries, for example, remote antenatal appointments with midwives are increasing, to ensure pregnancy monitoring and continuity of care that would otherwise be impossible in certain circumstances. Likewise, teleconsultations to prescribe a medication abortion are also increasing. This type of online service, which for a long time was the preserve of organizations fighting for access to abortion, has been integrated into official health services, including in the United Kingdom and the United States.

1.6. The progress and unintended consequences of medicalized reproduction

The Programme of Action placed great emphasis on the empowerment of girls and women, proposing quantified but non-binding targets for States. While clear progress has been made, particularly in education, gender inequalities still persist in many areas and reflect the deep-rooted tension between, on the one hand, the independence and empowerment of women and, on the other, the gender-based and patriarchal organization of society. Population policies, for example, whether they are antinatalist (such as the birth restriction policies of China and Vietnam and India’s sterilization campaigns) or pronatalist (as in Russia and Hungary), limit women’s ability to make reproductive choices freely.

In encouraging the development of sexual and reproductive health services and access to maternal health services, the Programme of Action did not anticipate the potentially harmful effects of certain technological advancements and the medicalization of pregnancies and childbirth. For instance, while Caesarean sections are effective in the prevention of maternal and neonatal mortality in certain situations, there are, according to the World Health Organization, no benefits to the general population if they are used for more than 10% of deliveries. At above 15%, the likelihood of unnecessary surgery entailing risks for women and newborns is high. And yet we have seen an explosion in the rate of Caesarean sections worldwide, rising from 12% in 2000 to 21% in 2015 [6]. At the regional level, rates reached an average of 27% in Europe, 30% in the Middle East and North Africa, and 44% in Latin America in 2015. Other risky interventions are also widespread, such as manual fundal pressure to accelerate labour. This obstetric practice, aimed at speeding up delivery by applying pressure to the abdomen, is controversial because its efficacy has never been proven, and it can lead to complications and trauma for the person in labour.⁵

Reproductive technologies such as ultrasounds and pre-implantation diagnostics ⁶ have been developed since the 1980s and enabled substantial advances in maternal and neonatal health screening. However, their use has also been misused to facilitate the aborting of female foetuses in certain Asian and European countries. In 2010, it was estimated that the world was missing 126 million women due to sex-selective abortions and excess mortality among young girls [8].

1.7. Recent reports of obstetric and gynaecological violence

More generally, the over-medicalization of pregnancies, births, and sexual and reproductive health more broadly raises the question of obstetric and gynaecological violence, instances of which have been reported since the 2000s in Latin America and since 2010 in Europe.⁷ This term includes gender violence experienced in the context of gynaecological consultations or during childbirth. It encompasses words and behaviour that are discriminatory, disrespectful, perceived as inappropriate, or violent, as well as medical procedures performed without prior information and consent. This type of violence reflects the patriarchal and paternalistic history of gynaecology and obstetrics which leads to a tendency to want to control women’s bodies [9]. Lack of financial and human resources at medical centres has a negative impact on the working conditions of healthcare staff and may be a contributing factor in cases of violence. Furthermore, some people are more vulnerable than others to obstetric or gynaecological violence due to their age, social background, race/ethnicity, and life choices. Violence of this kind has significant intimate, personal, family, and social consequences, as well as medical consequences since women who experience it may be less likely to seek medical attention in future.

1.8. Populations overlooked by the Cairo Programme of Action

The question of gender and sexual minorities (the lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) community) was not addressed in the Programme of Action since no global consensus on the topic was reached. Today, this community is much more visible, but there is still much work to be done to ensure that the sexual and reproductive rights of every individual are fully recognized. In the past, the sexual and reproductive health of LGBTQI+ communities was viewed through the prism of HIV/AIDS, due the devastating effects of this disease within these populations, in particular among men having sex with men. LGBTQI+ minorities are often deprived of access to adequate care and respect in healthcare services [10]. Likewise, in many countries, their access to ART (and adoption) is limited, which can hinder their desire to start a family. In some countries in which homosexuality is an offence or even a crime, their right to express their sexuality is already being violated: homosexual acts are punishable by a fine, imprisonment, or even death in 67 countries.⁸

In addition to sexual orientation, people can also be victims of violence and discrimination because of their gender, racial or ethnic origin, economic situation, or disability, which tends to limit their ability to exercise their sexual and reproductive rights. While the Programme of Action emphasized diverse sources of inequality—except those related to sexual minorities—the negative effect of the accumulation of several characteristics was not taken into account.

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In 2014, the Secretary General of the United Nations decided to renew the targets until they were achieved. In 2024, although major progress has been made in terms of access to contraception and maternal health services, fertility treatments, and the screening and treatment of STIs, we are still a long way from sexual and reproductive rights being recognized and exercised throughout the world. Many people remain deprived of their right to a free, healthy sex life and are prevented from achieving their parental ambitions due to their gender, sexual orientation or identity, or financial situation. In some countries, public spending cuts have reduced access to health and childcare services, restricting the sexual and reproductive rights of the poorest individuals, most of whom are still women. These women are then forced to forgo treatment or to choose between working and having children. Such policies, sometimes associated with conservative ideas that oppose gender equality, risk slowing down or even jeopardizing the progress made over the past 30 years.