We Can and Must Safeguard SRHR Progress and Resist Regression: We Have Come Too Far to Let It All Slip Away

24 February, 2025

Blog

 

This piece is written by Venkatraman Chandra-Mouli and Robert Blum

In November last year, I, Venkatraman Chandra-Mouli wrote an article titled: Why is a Harris-Walz win crucial for adolescent sexual and reproductive health? which set the stage for comparing the deficient and uneven state of school-based sexuality education in the USA with that in other parts of the world. That piece hinted at a better future if change were embraced. (1) 

Things did not turn out that way. Within weeks of their taking office, the enormous global damage that the Trump-Vance administration has begun to cause is evident. (2)

In the context of the huge backlash that the Trump Orders are creating all over the world, in this blog post, we are offering a space to reflect on the progress made on adolescent sexual and reproductive health in low-and-middle-income countries (LMIC), examine the concerning regression in the United States, and propose strategic actions for safeguarding—and even expanding—the gains achieved in LMIC over the past decades. 

Our first reflection is that over the last 25 years, many low-and-middle-income countries (LMIC) have moved ahead with government-led national programmes to provide adolescents with the sexual and reproductive (SRH) education and services they need. 

Contrary to many other countries, over the last quarter of a century, the USA regressed in providing its young people with SRH education and services and it appears likely that things will get worse in the future.  

Given the ongoing efforts of the Trump administration to undermine global institutions such as WHO and USAID, the drastic cuts in funding, the blocking of access to evidence contained in websites of USA-based institutions, and the reinstatement of the Mexico City Policy, the US Government has – in a flash – changed from a strong champion of SRHR to an active opponent to it. One can reasonably expect further deterioration in the situation in the USA, and stalling and regression in the progress made in LMIC. (2) 

Given this situation, researchers, academics, policymakers, politicians, government officials, non-government organisation (NGO) leaders, community members including parents and parents’ associations, and adolescents themselves around the world need to raise their voices separately and in unison, and even as importantly to redeploy resources/identify new resources where possible to meet the huge gaps that have emerged in programmes to meet the needs and fulfil the rights of adolescents.

 

Examples of progress from LMIC 

Zambia, Moldova and Nepal provide illustrative examples of the progress that a growing number of LMIC have made in implementing government-led programmes providing adolescents and young people with a range of sexual and reproductive health interventions including comprehensive sexuality education (CSE), medicines, commodities, and clinical services including contraceptive services and safe abortion care. Progress has been slow and uneven, but progress has been made.

 

Zambia: Providing School-based Comprehensive Sexuality Education

A review of the status of sexuality education worldwide led by UNESCO and published in 2021 noted that: “Data from 155 countries found that 85% report that they have policies, laws or legal frameworks related to sexuality education.” 

It noted though that: “Despite this favourable policy background, there remains a significant gap between policy and implementation on the ground.” (3) 

Multi-country initiatives such as the one in Eastern and Southern Africa have: ‘injected new energy into efforts to advance young people’s health, rights, and well-being at regional and national levels. (4) However, there is still much to be done. A 2021 UNAIDS Report noted that: “Globally, only one in three young people demonstrate accurate knowledge of HIV prevention.” (5)

In 1996, Zambia’s Ministry of Education recognised that educational attainment and CSE were intertwined. The government education policy “Educating our Future” underscored the importance of integrating life skills, sexuality and personal relationship education into the curriculum. 

In 2011, the Education Act and a National Life Skills Framework formalised the establishment of CSE in Zambia. In 2013, the revision of the school curriculum provided opportunities to strengthen CSE through the development of a CSE Framework for grades 5-12. This was integrated into the Zambia Education Core Framework in 2014 and rolled out nationwide. (6)  

Ten years later, the Make Way Programme partnered with the Forum for African Women Educationalists of Zambia to assess the impact of the programme on primary and secondary schools. Students in selected schools from districts in many parts of the country testified that the school-based CSE programme provided them with useful knowledge and a safe and judgement-free zone to discuss sensitive matters. (7) 

 

Moldova: Improving access to and uptake of contraceptives

Global efforts to increase access to and uptake of contraception have led to tangible benefits. In 2012 an estimated 260 million women and girls in low- and middle-income countries were using modern contraception. At the end of 2020, the estimated number was 320 million, an increase of 60 million. https://www.fp2030.org/news/arc-progress-2012-2020-what-you-need-know-final-fp2020-progress-report/ 

As of July 2024, the estimated number was 380 million, a further increase of 60 million. https://www.fp2030.org/measurement-report-2024/

Adolescent girls benefited from this as is evident from the increase in the proportion of girls whose needs for family planning were met by modern methods from approximately 49% to 60% between 2010 and 2020. (8)

The decade following Moldova’s independence in 1990 was a period of social and economic upheaval with negative impacts, particularly on the health of young people. As the health and social administrative structures of the country fell apart, international organisations rushed to assist. 

In the early 2000s, the government of Moldova prioritised young people. One of the activities they initiated – with external support – was to initiate pilot projects to make health services responsive and welcoming to young people, as part of wider efforts to revamp the antiquated health system, which focused only on curative care. (9)

Over the last 10 years, these initiatives have evolved to a point where today young people can obtain help from a national network of youth clinics financed through the National Health Insurance Company – which provides a package of health services following government quality standards. 

Services are further available to young people through family physicians and HIV Testing Centres. The Ministry of Health considers the needs and preferences of young people while making decisions about what health services to provide and what delivery strategies to use, resulting, for example, in providing outreach services to marginalised groups of young people. 

As a result of these efforts, the adolescent fertility rate declined from 34.2 per 1000 women 15-19 years of age in 2015, to 23.0 per 1000 women 15-19 years of age seven years later. Abortion rates also declined during the same period from 11.7 per 1000 women 15-19 years of age to 5.9 per 1000. The proportion of total births to adolescent mothers decreased from 7.1% in 2015 to 5.6% in 2022. (9) 

 

Nepal: Making safe abortion care legal and accessible 

Access to legal – and thereby safe – abortion care globally, has expanded since the International Conference on Population and Development (ICPD). In 2014, a Centre for Reproductive Rights report published to mark the 20th anniversary of the ICPD noted that: “During the past 20 years, more than 30 countries have liberalised their abortion laws, expanding the grounds under which women can legally access abortion services. 

Only a handful of countries have taken steps to legally restrict abortion or make it more difficult for women to procure abortions during this time” (10) This progress has continued since 2014; as the Center for Reproductive Rights notes: “Over the past 30 years, more than 60 countries and territories have liberalised their abortion laws. From Ireland to Nepal, abortion rights are becoming recognised as fundamental human rights for millions of people worldwide. And in Latin America, the Green Wave is ushering in a new era of liberalisation in Colombia, Mexico, Argentina, and elsewhere in the region. Only four countries have rolled back the legality of abortion – El Salvador, Nicaragua, Poland, and the USA”: https://reproductiverights.org/maps/worlds-abortion-laws/

At the start of the century, abortion care was illegal in Nepal and those who obtained an abortion in the country risked imprisonment. Safe abortion care was legalised in Nepal in 2002; up to 12 weeks of gestation women and girls could obtain safe abortion care legally. 

Further, there is a provision in the law for the time limit to be waived for medical reasons related to the pregnant woman or the unborn foetus. Safe abortion care services are available free of charge in public health facilities, and for a fee from private providers of abortion services. From the age of 16, young women do not require the consent of parents or guardians to obtain an abortion. While provider bias and social stigma continue to be challenging in obtaining abortion care, the overall situation has significantly improved.  (11, 12)

 

Reversal of progress in the United States of America 

Unfortunately, there has been a reversal of progress in adolescent sexual and reproductive health in the United States over the last 25 years. The regression is illustrated clearly when comparing the status of CSE provision, contraceptive information availability, reproductive health services and safe abortion provision today with where they were 25 years ago.

 

Comprehensive Sexuality Education (CSE)

In the USA, “squabbles over sex ed continued for years, but in the 1980s, AIDS changed everything. The rapid spread of HIV and AIDS alarmed Americans, especially at a time when there weren’t yet effective medical treatments, and led to a renewed interest in robust sexual education programmes. By 1993, 47 states had mandated sex ed for students — a monumental shift from just three states in 1980. As sex ed programs expanded all over the country, teens had less sex and teen birth rates decreased significantly.” The History of Sex Ed in the US – Nurx™

Hall et al echo this in their academic review. They note that there was steady progress in the provision of CSE between the late 1980s and the mid-1990s. The decline began in the second half of the 1990s. (13)

“In 1996, the Welfare Reform Act changed the course of CSE. This act included provisions to award tens of millions of dollars to Abstinence-Only Programmes. Five years later an additional $31 million was allocated in the federal budget for abstinence-only programs through the Special Projects of Regional and National Significance.”(https://sexedconference.com/the-history-of-sex-education/). 

As per the Sex Ed Report Card developed by the Sexuality Information and Education Council of the United States, SIECUS: “Sex education in the United States is a patchwork of state and local policies, resulting in significant disparities in the quality and comprehensiveness of sexual health instruction available to young people. Access to this critical information is often determined by the ZIP code in which they live.” This is illustrated by one data point from their report: 35 of 50 states require schools to emphasise abstinence when sexual education is provided: https://siecus.org/siecus-state-profiles/ 

Hall et al echo SIECUS’s lament: “Today, despite great advancements in the science, implementation of a truly modern, equitable, evidence-based model of comprehensive sex education remains precluded by sociocultural, political, and systems barriers operating in profound ways across multiple levels of adolescents’ environments.” (
13)

 

Access to and uptake of contraceptives

Birth control methods have been legally available to individuals of all ages, including unmarried young people, following two USA Supreme Court (SC) rulings in 1972 and 1978. Through the five decades of the 1970s, 1980s, 1990, 2000s, and 2010s, a range of new methods were approved for use and mechanisms were put in place to facilitate access.  

In 2010, the US Congress passed the Affordable Care Act (ACA), prohibiting sex discrimination in health insurance and requiring coverage of all preventive health care without copays. In 2011, the Obama Administration issued regulations defining preventive health care to include coverage of all USA Federal Drug Administration-approved forms of contraception. In 2013, the FDA approved over-the-counter sales of the emergency contraception Plan B for people below the age of 18. (An SC decision to do this for those aged over 18 had been made in 2006).   https://ourbodiesourselves.org/health-info/a-brief-history-of-birth-control

The retrogression began in the mid-2010s. In 2014, the SC ruled that employers with religious objections could refuse to cover contraception in their health insurance plans. In 2017, the first Trump Administration expanded the religious exemption from the ACA contraceptive mandate to employers of any size, even publicly traded businesses, and added an exemption for ‘moral objections’ of any kind. 

In 2019, the Trump Administration imposed a “domestic gag rule” on Title X healthcare clinics providing contraceptives to low-income women, resulting in a substantial reduction in the availability of reproductive health services in communities across the country. https://www.guttmacher.org/article/2020/02/trump-administrations-domestic-gag-rule-has-slashed-title-x-networks-capacity-half 

In 2020, the SC upheld the first Trump Administration’s religious and moral objections to the ACA thereby blocking access to insurance-covered birth control for tens of thousands of people across the country and disproportionately harming low-income women. (https://ourbodiesourselves.org/health-info/a-brief-history-of-birth-control). 

These barriers to access are accentuated by parental consent requirements in some states. 27 states and the District of Columbia explicitly allow all individuals to obtain contraceptive services without anyone else’s permission or those at a certain age (such as 12 or 14) and older to consent to such care. 19 states allow only certain categories of people younger than 18 to consent to contraceptive services (show signs of maturity, graduated high school, etc); and 4 states have no explicit policy or relevant case law. (https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law#)

 

Safe abortion care

With the SC having enshrined the right to abortion in their 1973 decision, Roe v Wade, the country’s citizens had the right to access safe abortion care and to have their privacy protected under Constitutional law. 

The right applies to all young people without parental consent; however, some states passed laws requiring parental notification  https://www.brennancenter.org/our-work/research-reports/roe-v-wade-and-supreme-court-abortion-cases). 

Over the last two decades, medical abortifacients have been approved for use, their regimens updated, and in-person dispensing requirements removed thereby contributing to easier access.  https://www.kff.org/womens-health-policy/fact-sheet/the-availability-and-use-of-medication-abortion/

In 2022 the right to safe and legal abortion was upended when the SC ruled that the right to access abortion was a state decision and no longer a protected right. “As a consequence, the United States now has a patchwork of laws ranging from total bans to access based on gestational age. Today, 12 states and the District of Columbia (DC) have protected the right to abortion (primarily through amending state constitutions) and an equal number have made it illegal.” (https://reproductiverights.org/maps/abortion-laws-by-state/). 

Adolescent access to safe abortion care is further restricted by consent requirements. Only two states and the District of Colombia place no age or parental consent requirements on abortion access. 20 states require at least one parent to provide consent before a girl younger than 18 years can obtain an abortion, while an additional 10 states require parental notification (but not consent).  (https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law#)

 

Implications for the next four years and beyond globally

Nepal, Zambia, Moldova and several other LMICs have made tangible progress on various aspects of sexual and reproductive health over the last 25 years. The US government, US foundations, and US-based international non-government organisations (INGOs) have contributed to these advances, directly or indirectly. Other multilateral agencies, bilateral agencies, foundations and INGOS have done so too. 

However, today the threats are mounting on different fronts. It seems highly likely that there will be a sharp decline in funding from the US government, reduced support from US-based governmental and non-governmental agencies, and relentless attacks on SRHR both by the US government, other copycat governments, and by emboldened non-state players in the USA and around the world.  

To safeguard and build on the advances made, champions for SRHR around the world must advocate with one voice to ensure that everyone has access to all sexual and reproductive health services. It is up to each of us to speak out, march in the streets, and lobby our respective governments. 

Alongside this, the world must accept the new reality and move ahead. This is an exceptional time. One that calls for new ideas, new ways of thinking and working, and new alliances and relationships. 

Pai et al argue, that this will require new ways of working and tapping into new sources of funding. (14) Ntusi goes a step further. He notes: “As bad as the crisis is, it presents an opportunity to reconceptualise global health and not only to reduce the reliance of the global south on the global north but also to consider an intentional approach to dismantling the skewed financial, epistemic and power dynamics of global health.” (15)

This is a huge crisis for the USA and the world. We are shocked and saddened but we cannot afford to be paralysed by it. We must get up, regroup and move ahead. We must work on three fronts – we must safeguard and build on the progress made in LMIC; we must counteract the attacks on LMIC orchestrated by state and non-state players; and those of us outside the USA must support champions in that country fighting the pushback both nationally and internationally, in any way they can.  

Together we will survive this crisis and build back better!

 

Dr Venkatraman Chandra-Mouli, Independent adolescent sexual and reproductive health and rights learner, communicator, advisor, teacher, and supporter of research, development and action (formerly a staff member of the World Health Organization). and Dr Robert Blum, Expert on adolescent health and development, and a staff member of the Johns Hopkins Bloomberg School of Public Health

Sources:

  1. Chandra-Mouli, Smith M. Why is a Harris-Walz win crucial for adolescent sexual and reproductive health. Sexual and Reproductive Health Matters blog. November 2024. https://www.srhm.org/news/why-is-a-harris-walz-win-crucial-for-adolescent-sexual-and-reproductive-health/
  2. Xu W. The US Administration Assault on Global Reproductive Health and Autonomy. Health and Human Rights Journal. February 13, 2025 https://www.hhrjournal.org/2025/02/13/the-us-administration-assault-on-global-reproductive-health-and-autonomy/
  3. UNESCO, UNFPA, UNICEF, UN Women, WHO. The journey towards Comprehensive Sexuality Education: A global status Report. UNESCO, Paris. 2021. https://unesdoc.unesco.org/ark:/48223/pf0000379607
  4. Watson K, Akwara E, Machawira P, Bakaroudis M, Tallarico R, Chandra-Mouli V. The East and Southern Africa Ministerial Commitment: a review of progress toward fulfilling young people’s sexual and reproductive health and rights (2013-2018). Sexual and Reproductive Health Matters. 2021 Dec;29(1):1982186. doi: 10.1080/26410397.2021.1982186. PMID: 34726585; PMCID: PMC8567873 https://www.tandfonline.com/doi/full/10.1080/26410397.2021.1982186
  5. UNAIDS. Young People and HIV, UNAIDS, Geneva, 2021. https://www.unaids.org/sites/default/files/media_asset/young-people-and-hiv_en.pdf
  6. UNESCO. Comprehensive Sexuality Education – Country Profiles, 2023: https://education-profiles.org/sub-saharan-africa/zambia/~comprehensive-sexuality-education
  7. Ninsiima E. A decade of Zambia’s Comprehensive Sexuality Education Framework: tangible wins amidst existing gaps. Make Way. 2024. https://www.make-way.org/a-decade-of-zambias-comprehensive-sexuality-education-framework-tangible-wins-amidst-existing-gaps/
  8. Akwara E, Chandra-Mouli V. Good progress in a number of areas of ASRH, but there is much more that needs to be done. Sexual and Reproductive Health Matters. 2023 Dec;31(1):2266657. doi: 10.1080/26410397.2023.2266657. Epub 2023 Oct 23. PMID: 37870260; PMCID: PMC10595384. https://www.tandfonline.com/doi/full/10.1080/26410397.2023.2266657
  9. Lesco G, Amo Adjei J, Chandra-Mouli V. A systems approach to advancing adolescent sexual and reproductive health and rights in Moldova, WHO, Geneva, 2024. Moldova Story Layout 2024 D1
  10. Center for Reproductive Rights. Abortion worldwide: 20 years of reform. Center for Reproductive Rights. Washington DC, 2014. https://reproductiverights.org/wp-content/uploads/2020/12/20Years_Reform_Report.pdf
  11. Thapa S. Abortion law in Nepal: the road to reform. Reproductive Health Matters. 2004 Nov;12(24 Suppl):85-94. https://www.tandfonline.com/doi/full/10.1016/S0968-8080%2804%2924006-X 
  12. Tamang A, Tamang J. Availability and acceptability of medical abortion in Nepal: health care providers’ perspectives. Reproductive Health Matters. 2005 Nov;13(26):110-9. doi: 10.1016/S0968-8080(05)26194-3. PMID: 16291492. https://www.tandfonline.com/doi/full/10.1016/S0968-8080%2805%2926194-3
  13. Hall KS, McDermott Sales J, Komro KA, Santelli J. The State of Sex Education in the United States. Journal of Adolescent Health. 2016 Jun;58(6):595-7. doi: 10.1016/j.jadohealth.2016.03.032. PMID: 27210007; PMCID: PMC5426905. https://www.jahonline.org/article/S1054-139X(16)30004-0/fulltext
  14. Pai M, Bandara S, Kyobutungi C. Shifting power in global health will require leadership by the Global South and allyship by the Global North. Lancet. 2024 Oct 24:S0140-6736(24)02323-7. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02323-7/abstract
  15. Ntusi. N. . US aid cuts are an opportunity to reimagine global health. The global south should become self-reliant by investing in health. Nature Medicine. World View, February 2025. https://www.nature.com/articles/d41591-025-00009-9