Reproductive Health

Health A state of complete physical, social, and mental well being and not merely the absence of disease or infirmity (WHO)

Health is a resource for every day life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities

Wellness - a dynamic, growing process includes self responsibility, daily decisions, good nutrition, stress management preventive care and emotional health

Illness - a highly personal state, in which persons physical, emotional, intellectual, social development or spiritual functioning is diminished

Disease - an alteration in body function resulting in a reduction of capacity or shortening of normal life span

UN brought 180 nations together at Cairo for a 20-year program of action to arrive at:

• - Promotion of Human Development

• - Stabilized Population Growth

• - Improve Human Health, Education and Rights.

International Conference on Population and Development 1994

Reproductive Health Definition

People have the ability to • Reproduce• Regulate their fertility• Safely go through pregnancy and childbirth• Get a successful pregnancy outcome (infant and child

survival and well-being) • Enjoy safe sex

Reproductive RightsCouples are free and responsible to:

decide about the number and spacing of their children, with all information and means to do so

attain the highest standard of sexual and reproductive health make decisions free of discrimination, coercion or violence

Reproductive Health PackageD e v e l o p e d f o r Pa k i s t a n i n 1 9 9 9 b y m u l t i p l e s t a ke h o l d e r s

Comprehensive Family Planning

Pre - post- and natal care & Infant care

Adolescent Care

Prevention and treatment of infertility and abortion

Treatment of STIs/RTIs/HIV

Prevention and treatment of cancers

Management of menopausal/elderly problems

Management of RH issues related to men

Active discouragement of harmful practices (domestic violence; gender inequity)

R H – Life Cycle Approach

Why Sexual & Reproductive Health

Over 350 million people around the world lack access to comprehensive information and services pertaining to pregnancy, contraception and child birth

75 million unwanted pregnancies annually

Every day 1600 women die from complications of pregnancies and child birth

Complications related to pregnancies is the number one cause of death for women aged 15-19

Over a million are effected every day with STI’s

RH indicators in Pakistan

MMR 300-600 per 100,000 live births

IMR : 94 per 1000 live births

CPR: 31%

TFR: 3.1%

ANC coverage 28%

Attended delivery 34%

HIV/AIDS prevalence 0.1%

RH indicators in Pakistan

500,000 Mothers are dying over the globe yearly

25-30,000 Mothers are dying in Pakistan each year

One mother is missing after every 20 min. in Pak.

Mortality in F-children is 66 to 100% high in 1-4 and 5-9 year age groups

Maternal causes are one of the leading causes of mortality & morbidity in female poipulation.

Social determinants Age at marriageAge of child bearingChild spacingFamily sizeFertility patternsEducation Economic statusCustoms & beliefs Womens’ role in income generation

Postpartum Care for Newborn & Mother

Behavioral Determinants

Labor & Delivery Care

AntenatalCare

ImmediateNewbornCare

Special Care

Special Care

Special Care

Birth Asphyxia

LBW

DangerSigns

Special Care

DangerSigns BDBD

BD BD BD BD

BD BD

•Norms•Knowledge•Attitudes•Beliefs•Skills•Self-efficacy

ADOLESCENCE

The World Health Organization defines adolescence as the period between 10 and 19 years of age

Adolescents comprise almost 1/5th of the world's population

There are more than 1 billion young people ages 10 to 19

In Pakistan, 1/4th of the population comprises of adolescents

Adolescent RH: Why a Special Concern?

Special reproductive health risks

Socio-cultural barriers to access to health care

Less informed, less experienced and less comfortable in accessing RH services

In conflict as need independent action, decision-making and emotional separation from their parents, while at the same time still feeling dependent on their parents for emotional, physical and financial support

ADOLESCENT ISSUESPhysical Changes

Psychological Changes

Social Changes

Physical Changes Adolescents may feel worried and embarrassed about body

changes, growth of hair, acne

feel self conscious about their body and how they look

Girls may become very sensitive and emotional just before menstruation

Psychological Changes

* They often feel awkward, shy and confused

* Changes in mood - feeling high or low- without reason

* Strong need for acceptance leads to giving more importance to their peers than their parents

* Feelings of anger, confusion and depression

Social Changes Fond of going out with friends than staying at home

Tend to engage in risky and dangerous behavior

Attracted towards the opposite sex

Curious to learn what place sexual expression has in relationships

Onset of Sexual ActivityBeginning exposure to sexual activity

Exposure to health risks

• STD and HIV infection

• Early childbearing

Coincidence with timing of marital union

Cultural norms

• Gender differences

Adolescents Health Risks

Early and unintended pregnancy: 40% of women give birth before age 20 in developing world

Unsafe abortions: up to 4.4 million abortions each year among adolescents

Increased risk of STDs: 60% of all new infections occur among 15 to 24 year olds

Harmful traditional health practices: 2 million girls undergo female genital cutting each year

Other Health Risk FactorsSmokingAlcohol and drug usePhysical abuseMental health (depression)Infection

• Malaria• STD and HIV

Adolescent Reproductive Health: Programmatic Challenges

Adolescent sexuality: A sensitive subject in all cultures

A hard to reach group

Health care providers’ bias against adolescents

Recommendations

Programs should target parents in order to improve communication with young people regarding health issues (esp. girls)

Schools/ teachers can play an important role in imparting RH knowledge

Community programs should target peer group networks to reach boys

Life skills training essential to deal with later RH problems

Young husbands and wives should receive counseling on delaying first birth

Infections

STI’s

Infections communicated by sexual contact and through exchange of body fluids

RTI’s

All infections of the reproductive tract including those not cause by sexual contact

Infections - a Pubic Health Concern? 40 million people are infected with HIV/AIDS.

18 million people are living with HIV/AIDS

7.3 million are women

4.5 million are men

340 million people infected each year with curable STIs

Nearly 1 million new cases occur each day Responsible for greatest number of healthy years lost, after maternal causes,

among women of reproductive age group in developing countries (excluding HIV/AIDS)

STIs and Reproductive HealthEstimated annual number of new cases

• Syphilis 6.5 million• Gonorrhea 31.5 million• Chlamydia 47.0 million• Trichomoniasis 80.0 million

>50% of STIs in women are asymptomatic

Diagnosis is difficult

Access to STI services is poor; quality of services also poor.

Women• Preterm delivery• Premature rupture

of membranes• Puerperal sepsis• Postpartum

infection

Infants• Stillbirth• Low birth weight• Conjunctivitis• Pneumonia• Neonatal sepsis• Congenital

abnormalities

Major Consequences of STIs Pregnancy Complicati ons

PREVENTION

AWARENESS & BEHAVIOR CHANGE

SAFER SEX

ELIMINATING STIGMA

GENDER EQUITY

AWARENESS & BEHAVIOR CHANGECOMFORT

ENHANCE SELF-ESTEEM

COMPLETE/CORRECT AGE APPROPRIATE INFORMATION

POSITIVE BODY IMAGE

NON JUDGMENTAL ATTITUDE

RESPECT

LANGUAGE

Impact of HIV/AIDS on Health

Direct effect: through AIDS deaths

• Reversal of past gains in child survival

• Decline in life expectancy Indirect effects

• Strains on the health system

• Facilitation of spread of other diseases, e.g., tuberculosis

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Trends in Pregnancy & Delivery

A large proportion of home deliveries (82%)

Contraceptive Prevalence Rate is 34%

Unmet need for FP is 33%

Safe Motherhood

Essential obstetric services

• Quality routine antenatal and delivery care

• Emergency services

Avoidance of unintended pregnancies

Safe abortion or post-abortion care

Delivery of post-abortion and post-partum family planning

Challenges

Abortion

Approximately 25 million legal abortions annually (1 in 6 births)

• Much higher if unreported illegal abortions included

• About 20 million unsafe (1 in 7 births)

Total Number of Induced Abortions (Annual)

Pakistan 890,000

Punjab 457,000

Sindh 218,000

NWFP 160,000

Balochistan 54,500

Total Number of Women Hospitalized for Complications of Abortion (Annual)

Induced Spontaneous

Total

Pakistan 197,000 53,000 250,000

Punjab 98,000 30,000 128,000

Sindh 46,000 13,000 59,000

NWFP 41,000 7,000 48,000

Balochistan 12,000 3,000 15,000

ContraceptionNatural Method

Barrier contraception

Oral Contraceptives

Injectable contraceptives

Hormonal Implants

Skin Patches

Uterine Devices

Surgery

Breast CancerIncidence is lower in developing countries

than developed

Rising trends ---

Risk factors include

• early menarche

• late menopause

• late child bearing

• short duration of breast feeding

• HRT

• radiations

Cancers of uterus

Endometrial cancers

• Most common malignancy in western population.

• 6% of all incident cancers

• Steady fall in death rate

• Rare before 40, rapid increase after 44 years

Ovarian cancers

Common in developed countries

4th most common cancer in women

Poor survival –

6% of cancer deaths

Rare before 35

5 year survival only 30%

MENOPAUSE

Vasomotor Urogenital Psychological Others Long Term

Hot flushes/flashes Sweating Palpitations Dizziness

Irregular bleeding Incontinence Pain during intercourse Genital prolapse Urinary and Resp. Tract infections Itching

Anxiety Irritability Inability to concentrate

Insomina Backache Headache Fluid Retention Thinning of skin

Heart disease Osteoporosis Cancer (breast and cervix)

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Sexua l i ty among o lder women.

Decreased libido…..??• Illness and medications (especially antihypertensive agents,

antipsychotics, and antidepressants)

• impaired self-image

IMPACT OF AGING ON WOMEN

Age discrimination

Gender discrimination

Low social status ---step into old age with poor health

Rejection by children

Over burdened by the role as family care giver

Health needs of older women

From birth spacing to prevention child bearing

Menopausal Symptoms

New long term health risksOsteoporosisCardiovascular disorders

Mental health problem

Reproductive health disorders including malignancies

Designing Health Services for Old Age

Diet, exercise and other healthy life style

Treatment of genitourinary tract infections, genital prolapse and fistulae.

Services and treatment for cancer

Counseling and treatment of menopausal symptoms.

Medical management of risk factors.

Out reach activities (Support group services and volunteer health promoters)

Gender-based Violence and Reproductive Health

Herrera/Mexfam

Types of Violence

M. Ramos/ReproSalud/Herrera

Physical

Psychological

Sexual

Psychological

Reducing Violence

Gender-based violence is a major public health problem

Violence directly affects women’s reproductive health

Effect of Violence on Women’s SRHInvoluntary sexual activity

Unintended/unwanted pregnancy

Unsafe abortion

Reduced ability to negotiate condom use

STI/HIV transmission

High-risk pregnancies and maternal deaths

Covert contraceptive use

Depression and low self-esteem

Psychosocial Risk Factors in Violence against Women

Witnessing marital violence as a child

Being abused as a child

Absent/rejecting father

Alcohol/drug use

Mexfam

Gender Roles and Partner Abuse

Men feel entitled to be served by women

Failure to meet men’s expectations can lead to violence

Many cultures sanction physical abuse as a way to “correct” women’s behavior

In some cultures, men use extreme violence to maintain gender “honor”

Is a greater orientation of RH interventions toward community

engagement possible in Pakistan?

THE REPRODUCTIVE HEALTH STAIRCASE

GIRL BORN UNDER WEIGHT  

  No celebration  

  Poor breastfeeding  

  Inadequate solid foods  

  Poor immunization  

  Poor sanitation

Infectious diseases  

  Poor treatment  

  Poor schooling  

  Early marriage (age 15)  

  Quick pregnancy  

  Poor prenatal care  

Give birth to under weight girl > 1 . No celebration 2 ,3,4 etc > next generation

 

 

No talk with husband about RH

 

  No contraception  

  Pregnancy  

 Gives birth to under weight boy

1 Celebration  

  Blamed, Beaten 2 Neonatal tetanus  

  Pregnancy 3 Treatment fails  

  Complications Dies, age 6 days  

  No proper treatment

  SHE DIES: age 19  

Farzana: A true storyFarzana is a 28 year old woman who went for the first time to the local maternity

home to deliver her baby. She already has five children, all girls. This is her eighth pregnancy. Being an unplanned pregnancy, she had attempted an illegal abortion in her fourth month which was not successful. She begs the doctor to deliver a boy because her husband will divorce her otherwise. The doctor finds this funny and calls her jahil and irresponsible. She tells all the other staff and they all have a laugh at being asked to deliver a boy

After a prolonged labour, the doctor decides to operate on Farzana. A member of the staff hurriedly gets the husband to sign a consent form and explains nothing. During the procedure, the doctor performs a sterilization operation to save her further problems

Farzana delivers a beautiful, but small, baby girl. Her husband is furious with her and decides to divorce her as she is not capable of providing him with a son

What Rights were violated?Called jahil – (illiterate)

Right to dignity/ respect

Doctor did not tell how the sex of a baby is determined Right to information

No consent taken for sterilization Right to make decision

Pregnancy was unplanned Right to contraceptive information and servicesRight to decide number and spacing of children

Impact of these violations

1. On Farzana Guilt / shame / Anxiety/ depression Feelings of helplessness Will not access formal health care services for the fear of humiliation and

discrimination Economic burden Divorce – fear of losing children

2. On her family• Economic burden• Health and education priorities overridden• Divorce – impact on children /Feeling that dishonor has been brought to the family

3. On the community at large• Myth that sex of child is determined by the woman will perpetuate• Other women will fear similar treatment when seeking health care services • Unsafe abortions will continue

THANKS