But the plan is being threatened, says Dr Shereen El Feki, acclaimed health-care correspondent at The Economist magazine, by ideological battles, a severe shortfall in international funding for reproductive health, and the HIV pandemic, which shows no sign of slowing.

In a provocative essay published today, as a "sneak peak" of the October launch issue of PLoS Medicine (http://www.plosmedicine.org), the new open access global health journal from the Public Library of Science, Dr El Feki argues that since the Cairo Conference, "a fierce battle has emerged between religious conservatives who eschew abortion and condoms in favour of abstinence and fidelity, and more liberal voices who argue for a full armamentarium."

The fight between conservatives and liberals is clearest, she argues, in the case of the US. Although it spends more than any other country on reproductive health--$429 million this year--the money comes with strings attached. For example, under the Mexico City Policy (the "Global Gag Rule"), which George W. Bush reinstated in 2001, US family planning assistance cannot be given to any non-American non-governmental group unless it certifies that it neither performs nor endorses abortion. "International Planned Parenthood Federation (IPPF), Marie Stopes International and their local affiliates have been hard hit by the Rule," says Dr El Feki, "scaling back services in Kenya, Ghana and elsewhere offering essential health-care to thousands of women and children."

These ideological battles are compounded by rich countries neglecting the commitments they made at the Cairo conference. "Rich country contributions reached an estimated $2.3 billion in 2003, a far cry from the conference target of $6.1 billion (or $8.1 billion in today's dollars) by 2005."

At the time of the Cairo conference, 20 million people were infected with HIV; now it is 38 million. Although the world is scaling up AIDS prevention and treatment to millions worldwide, few of the agencies involved come from the world of reproductive and sexual health. "This is a pity because it fails to make use of valuable infrastructure and expertise already on the ground in places where AIDS hits hardest", says Dr El Feki.

Such obstacles yield sobering statistics: 60 million unwanted pregnancies, 19 million unsafe abortions, and over half a million women dying from complications of pregnancy and childbirth every year.

"Getting it right on reproductive health cannot wait another decade," says Dr El Feki. "The largest generation of young people in history...is entering adulthood. They are making their sexual debut at ever earlier ages, against a backdrop of rising sexually-transmitted diseases and growing social conservatism, which makes clear information, frank discussion and free choice on abortion, contraception and sexual health extremely difficult."

Dr. El Feki's article is published under an open access license--anyone, anywhere in the world is free to download, distribute, and reuse it freely as long as the article is properly cited.

Citation: El Feki S (2004) The birth of reproductive health: A difficult delivery. PLoS Med 1(1): e009.