women and girls who are or are likely to be sexually active, are at risk of pregnancy and are not married or "in-union". three related targets of mdg5 were adolescent birth rate, contraceptive prevalence and unmet need for family planning (where prevalence+unmet need = total need), which were monitored by the population division of the un department of economic and social affairs. contraceptive use was part of goal 5b (universal access to reproductive health), as indicator 5.3. the evaluation of mdg5 in 2015 showed that amongst couples usage had increased worldwide from 55% to 64%. with one of the largest increases in subsaharan africa (13 to 28%). the corollary, unmet need, declined slightly worldwide (15 to 12%). in 2015 these targets became part of sdg5 (gender equality and empowerment) under target 5.6: ensure universal access to sexual and reproductive health and reproductive rights, where indicator 5.6.1 is the proportion of women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care (p. 31). there remain significant barriers to accessing contraception for many women in both developing and developed regions. these include legislative, administrative, cultural, religious and economic barriers in addition to those dealing with access to and quality of health services. much of the attention has been focussed on preventing adolescent pregnancy. the overseas development institute (odi) has identified a number of key barriers, on both the supply and demand side, including internalising socio-cultural values, pressure from family members, and cognitive barriers (lack of knowledge), which need addressing. even in developed regions many women, particularly those who are disadvantaged, may face substantial difficulties in access that may be financial and geographic but may also face religious and political discrimination. women have also mounted campaigns against potentially dangerous forms of contraception such as defective intrauterine devices (iud)s, particularly the dalkon shield. abortion main article: abortion women demonstrate for abortion rights, dublin, 2012 abortion is the intentional termination of pregnancy, as compared to spontaneous termination (miscarriage). abortion is closely allied to contraception in terms of women's control and regulation of their reproduction, and is often subject to similar cultural, religious, legislative and economic constraints. where access to contraception is limited, women turn to abortion. consequently, abortion rates may be used to estimate unmet needs for contraception. however the available procedures have carried great risk for women throughout most of history, and still do in the developing world, or where legal restrictions force women to seek clandestine facilities. access to safe legal abortion places undue burdens on lower socioeconomic groups and in jurisdictions that create significant barriers. these issues have frequently been the subject of political and feminist campaigns where differing viewpoints pit health against moral values. globally, there were 87 million unwanted pregnancies in 2005, of those 46 million resorted to abortion, of which 18 million were considered unsafe, resulting in 68,000 deaths. the majority of these deaths occurred in the developing world. the united nations considers these avoidable with access to safe abortion and post-abortion care. while abortion rates have fallen in developed countries, but not in developing countries. between 2010 and 2014 there were 35 abortions per 1000 women aged 15–44, a total of 56 million abortions per year. the united nations has prepared recommendations for health care workers to provide more accessible and safe abortion and post-abortion care. an inherent part of post-abortion care involves provision of adequate contraception. sexually transmitted infections main article: sexually transmitted infections important sexual health issues for women include sexually transmitted infections (stis) and female genital cutting (fgc). stis are a global health priority because they have serious consequences for women and infants. mother-to-child transmission of stis can lead to stillbirths, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities. syphilis in pregnancy results in over 300,000 fetal and neonatal deaths per year, and 215,000 infants with an increased risk of death from prematurity, low-birth-weight or congenital disease. diseases such as chlamydia and gonorrhoea are also important causes of pelvic inflammatory disease (pid) and subsequent infertility in women. another important consequence of some stis such as genital herpes and syphilis increase the risk of acquiring hiv by three-fold, and can also influence its transmission progression. worldwide, women and girls are at greater risk of hiv/aids. stis are in turn associated with unsafe sexual activity that is often unconsensual. female genital mutilation traditional african midwife explaining the risks of fgc for childbirth at a community meeting female genital mutilation (also referred to as female genital cutting) is defined by the world health organization (who) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons". it has sometimes been referred to as female circumcision, although this term is misleading because it implies it is analogous to the circumcision of the foreskin from the male penis. consequently, the term mutilation was adopted to emphasise the gravity of the act and its place as a violation of human rights. subsequently, the term cutting was advanced to avoid offending cultural sensibility that would interfere with dialogue for change. to recognise these points of view some agencies use the composite female genital mutilation/cutting (fmg/c). it has affected more than 200 million women and girls who are alive today. the practice is concentrated in some 30 countries in africa, the middle east and asia. fgc affects many religious faiths, nationalities, and socioeconomic classes and is highly controversial. the main arguments advanced to justify fgc are hygiene, fertility, the preservation of chastity, an important rite of passage, marriageability and enhanced sexual pleasure of male partners. the amount of tissue removed varies considerably, leading the who and other bodies to classify fgc into four types. these range from the partial or total removal of the clitoris with or without the prepuce (clitoridectomy) in type i, to the additional removal of the labia minora, with or without excision of the labia majora (type ii) to narrowing of the vaginal orifice (introitus) with the creation of a covering seal by suturing the remaining labial tissue over the urethra and introitus, with or without excision of the clitoris (infibulation). in this type a small opening is created to allow urine and menstrual blood to be discharged. type 4 involves all other procedures, usually relatively minor alterations such as piercing. while defended by those cultures in which it constitutes a tradition, fgc is opposed by many medical and cultural organizations on the grounds that it is unnecessary and harmful. short-term health effects may include hemorrhage, infection, sepsis, and even result in death, while long term effects include dyspareunia, dysmenorrhea, vaginitis and cystitis. in addition fgc leads to complications with pregnancy, labor and delivery. reversal (defibulation) by skilled personnel may be required to open the scarred tissue. amongst those opposing the practice are local grassroots groups, and national and international organisations including who, unicef, unfpa and amnesty international. legislative efforts to ban fgc have rarely been successful and the preferred approach is education and empowerment and the provision of information about the adverse health effects as well the human rights aspects. progress has been made but girls 14 and younger represent 44 million of those who have been cut, and in some regions 50% of all girls aged 11 and younger have been cut. ending fgc has been considered one of the necessary goals in achieving the targets of the millennium development goals, while the united nations has declared ending fgc a target of the sustainable development goals, and for february 6 to known as the international day of zero tolerance for female genital mutilation, concentrating on 17 african countries and the 5 million girls between the ages of 15 and 19 that would otherwise be cut by 2030. infertility main article: infertility in the united states, infertility affects 1.5 million couples. many couples seek assisted reproductive technology (art) for infertility. in the united states in 2010, 147,260 in vitro fertilization (ivf) procedures were carried out, with 47,090 live births resulting. in 2013 these numbers had increased to 160,521 and 53,252. however, about a half of ivf pregnancies result in multiple-birth deliveries, which in turn are associated with an increase in both morbidity and mortality of the mother and the infant. causes for this include increased maternal blood pressure, premature birth and low birth weight. in addition, more women are waiting longer to conceive and seeking art. child marriage poster addressing the 2014 london girl summit dealing with fgm and child marriage child marriage (including union or cohabitation) is defined as marriage under the age of eighteen and is an ancient custom. in 2010 it was estimated that 67 million women, then, in their twenties had been married before they turned eighteen, and that 150 million would be in the next decade, equivalent to 15 million per year. this number had increased to 70 million by 2012. in developing countries one third of girls are married under age, and 1:9 before 15. the practice is commonest in south asia (48% of women), africa (42%) and latin america and the caribbean (29%). the highest prevalence is in western and sub-saharan africa. the percentage of girls married before the age of eighteen is as high as 75% in countries such as niger (nour, table i). most child marriage involves girls. for instance in mali the ratio of girls to boys is 72:1, while in countries such as the united states the ratio is 8:1. marriage may occur as early as birth, with the girl being sent to her husbands home as early as age seven. there are a number of cultural factors that reinforce this practice. these include the child's financial future, her dowry, social ties and social status, prevention of premarital sex, extramarital pregnancy and stis. the arguments against it include interruption of education and loss of employment prospects, and hence economic status, as well as loss of normal childhood and its emotional maturation and social isolation. child marriage places the girl in a relationship where she is in a major imbalance of power and perpetuates the gender inequality that contributed to the practice in the first place. also in the case of minors, there are the issues of human rights, non-consensual sexual activity and forced marriage and a 2016 joint report of the who and inter-parliamentary union places the two concepts together as child, early and forced marriage (cefm), as did the 2014 girl summit (see below). in addition the likely pregnancies at a young age are associated with higher medical risks for both mother and child, multiple pregnancies and less access to care with pregnancy being amongst the leading causes of death amongst girls aged 15–19. girls married under age are also more likely to be the victims of domestic violence. there has been an international effort to reduce this practice, and in many countries eighteen is the legal age of marriage. organizations with campaigns to end child marriage include the united nations and its agencies, such as the office of the high commissioner for human rights, unfpa, unicef and who. like many global issues affecting women's health, poverty and gender inequality are root causes, and any campaign to change cultural attitudes has to address these. child marriage is the subject of international conventions and agreements such as the convention on the elimination of all forms of discrimination against women (cedaw, 1979) (article 16) and the universal declaration of human rights and in 2014 a summit conference (girl summit) co-hosted by unicef and the uk was held in london (see illustration) to address this issue together with fgm/c. later that same year the general assembly of the united nations passed a resolution, which inter alia urges all states to enact, enforce and uphold laws and policies aimed at preventing and ending child, early and forced marriage and protecting those at risk, and ensure that marriage is entered into only with the informed, free and full consent of the intending spouses (5 september 2014) amongst non-governmental organizations (ngos) working to end child marriage are girls not brides, young women's christian association (ywca), the international center for research on women (icrw) and human rights watch (hrw). although not explicitly included in the original millennium development goals, considerable pressure was applied to