REPRODUCTIVE HEALTH

By: Adam F. Izzeldin; BPEH, MPH, PhD candidate.

Department of International Health, TMDU
Contents
Contents

Definition and components of reproductive health?

Demographic trends and fertility determinants

Family planning

Impact of reproductive patterns on child health

Impact of reproductive patterns on women health

Mechanisms to reduce morbidity and mortality.

What is reproductive health?

Within the framework of WHO's definition

of health as a state of complete
physical, mental and social well-being,
and not merely the absence of disease
or infirmity, reproductive health
addresses the reproductive processes,
functions and system at all stages of
life. Reproductive health, therefore,
implies that people are able to have a
responsible, satisfying and safe sex life
and that they have the capability to
reproduce and the freedom to decide if,
when and how often to do so.
(WHO)
Components of reproductive health

• Family-planning counseling, information,

education, communication and services;
• Education and services for prenatal care,
safe delivery, and post-natal care, especially
breast-feeding, infant and women's health
care;
• Prevention and appropriate treatment of
infertility; abortion; sexually transmitted
diseases; and reproductive tract infections
• information, education and counselling, as
appropriate, on human sexuality,
reproductive health and responsible
parenthood.
Reproductive health links

• Reproductive health tied to policy

concerns about population growth as
well as health.
• International Conference on Population
and Development in Cairo 1994 focused
on population while two previous
international conferences emphasized on
family planning.
• In 2000 , the United Nation Millennium
declaration was adopted as a
commitment; however, goal 5 is to
improve maternal health (by reducing
maternal mortality three quarters).
Demographic trends and fertility determinants

• World population reached 1 billion just after 1800.

• But it took less 125 years to add the second billion in
1930.
• In 1960 the world passed the third billion.
• Within 40 years ahead the population doubled to be
6 billions in 2000.
• In year 2010 the world population reached 7 bilion.
• The majority of this expansion has taken place in
developing countries.
• The encouraging news is that the rate of growth is
declining since 1960.
World population growth

Source: United nation population division

Population size by continent, 1950-2100
The world population growth rate

2010
The process of fertility

Marriage Sterility

Effective reproductive span

Birth of Menarche Marriage Death of

woman dissolution woman

Start of B1 B2 B3 B last End of exposure

marriage to risk

Postpartum Time to Time to pregnancy

amenorrhea conception conception

B2 Resumption conception Fetal loss conception B3

of menses
Deliberate control of fertility

1. Reducing the effective

reproductive span through
postponement of marriage or
interrupted marriage or by
sterilization that ends
reproductive capacity early.
2. Using contraception, which
increases the time to
conception.
3. Abortion, which increases the
time added to birth interval by
pregnancies that do not lead to
live birth
The effect on fertility of the proximate
determinants: Bongaart’s Indices

• The index of postpartum infecundity:

The proportion of potential fertility, TF, when the average
of postpartum period of the population of interest is
taken into account.
• The index of abortion:
The proportion of TF, after postpartum first taken into
account.
• The index of contraception:
The proportion of TF, after the effect of postpartum
infecundity and induced abortion taken into account.
• The index of marriage:
The proportion of TF, after the first three factors are
considered. TFR= TF
Family planning

• The rationale is to reduce unintended fertility

because of its negative health and welfare
consequences and because it has been recognized
as a human right .
• Over the last 50 years, the dissemination of modern
ideas bout small families was adopted.
• In part, due to lack of availability , accessibility, and
effective contraceptive, the gap between observed
and desired fertility is grew, leading to in turn to an
increase to unintended fertility.
• According to WHO, in 2005 out of 211 million
pregnancies, 87 million women became pregnant
unintentionally.
Family planning methods

Region Sterilization Pill IUD Condom Total

Female Male

World 21.0 4.0 7.0 15.0 5.0 61.0

Low and middle income countries

Africa 2.0 0.1 7.0 5.0 1.0 26.0

Asia 25.0 4.0 5.0 18.0 4.0 64.0
Latin America 31.0 2.0 13.0 8.0 4.0 70.0
Oceania 12.0 9.0 21.0 2.0 9.0 59.0
Industrialized region
Japan 3.0 0.6 0.8 1.5 43.0 56.0
Europe 4.0 2.0 16.0 15.0 10.0 67.0
Northern America 23.0 14.0 15.0 1.0 13.0 76.0
New Zealand 14.0 19.3 20.5 3.3 11.0 74.0
Barriers for family planning

• The economic cost of access

to services, including
transportation and supplies.
• The social cost, including
traditional constrains, and
women movement.
• Psychic cost of contraceptive
use in a society that offer little
support for small family.
• The health cost of side effects,
whiter subjective or objective,
from contraceptive use.
Consequences of unintended pregnancy

• Abortion: represents 20%

of all pregnancies (WHO
estimates 20 million unsafe
abortion annually accounts
from 13% of maternal
deaths)
• Poor infant health with high
morbidity and mortality.
• Lower investment in human
capital (allocation f
resources for education
and health).
Organization of family planning program

• Focus on commitment to achieve

program objectives and access to
adequate resources.
• Placing the family planning program
under a national supervisory council
or by establishing a separate ministry.
• Collecting data on indicators such as
contraceptive prevalence, proportion
of unwanted births, maternal
morbidity and mortality, pregnancy
complications and their management,
and actual fertility level.
Intervention levels of family planning

Health center
community

Information, education, and communication menstrual regulation or vacuum aspiration

abortion

Community-based distribution Surgical contraception/ post abortion

counseling and contraception

counseling and treatment of

Social marketing of condoms and pills contraceptive side effects

Family
Health post District Hospital
planning
Counseling/ screening for contraception Surgical contraception

Counseling/ referral for menstrual Abortion through 20 weeks

regulation or abortion

Inject able contraceptive/ IUD/ counseling post abortion counseling and

and treatment of contraceptive side effects contraception
Strategies of Bangladesh Family planning
Diagram

Strategy 1 Strategy 2 Strategy 3 Strategy 4

Improving Community
coverage and Fostering development and
Awareness and
quality of village- demand creation
motivation (
services ( 5 based and (improving status of
mass media,
miles clinics, household women through
focused
free of charge services other program such
programs)
sterilization, (outreach) as micro-credit and
home service) education).
Impact of reproductive patterns on
child health
Reproductive pattern Mechanism through which child health affected

First born child Higher frequency of death (parents less experienced in child care,
poor intrauterine growth)
Higher-order children Cumulative maternal injuries “maternal depletion syndrome” leads to
poor intrauterine growth.
Large families Competition for limited resources (disproportionate girls)

Child born to very young Inadequate development of reproductive system causes maternal
mother risks, and inexperience in prenatal care and delivery
Child born to older mother Greater risk of birth trauma and genetic abnormality

Short interbirth intervals Inadequate maternal recovery (depletion);similar-age siblings

competition; termination of breastfeeding; low-birth, infections
Unwantedness Conscious or unconscious neglect; child born in stressful situation

Maternal death or illness Early termination of breastfeeding; no maternal care; disease may
be passed to child
Contraceptive use Hormonal contraception may interrupt braestfeeding
Maternal health

• Pregnancy is one of major health

risks for women in in low-and middle-
income countries.
• Nearly 536,000 women die worldwide
each year due to pregnancy related
causes, and the vast majority (99%)
of these deaths in low- and middle-
income countries.
• Although these numbers are
alarming,230 million pregnancies
and approximately 118 million births
occur annually in the world in safe
reproduction.
Confusion in definitions of maternal deaths

• Definition for Maternal deaths which defined as

deaths of woman while pregnant or up to 42
days post delivery from any cause accept
accidents. (undercount deaths up to 90 days).
• Maternal risk measurements are conceptually
distinct.
1.Maternal mortality ratio: the number of maternal
deaths to the number of pregnancies (LB)
2.Maternal mortality rate: the number of maternal
deaths divided by the number of women of
reproductive age (15 – 49 years old)
3. Life time risk: chance of dying from pregnancy
related cause.
Maternal mortality risks

• In sub-Saharan Africa and South Asia, maternal

mortality ratio of 800 maternal deaths per 100,000 live
births have been reported.
• The disparity between low- and middle-income and
high-income countries is much greater for maternal
mortality ( 20 times higher risk of maternal death per
pregnancy) than infant mortality ( 10 time s higher risk
of infant death per pregnancy).
• Life-time risk of maternal mortality vary from 1/75 in
low- and middle-income countries to 1/7,300 in high-
income countries.
• Maternal mortality ratios are 50 times higher (450
death/100,000 LB in low- and middle-income countries
vs. 9 deaths/100,000 LB in high-income countries )
Total Fertility Rate, Maternal Mortality Ratios, and
Lifetime Risk of Maternal Death by region,2005. source:
Population Reference Bureau (2008)
Region Total Fertility Maternal Maternal Deaths
Rate (Birth per Mortality Ratio
woman) (Deaths per Lifetime Risk Death per year
100,000 LB)
World 2.6 400 1 in 92 536,000

Industrialized 1.7 9 1 in 7,300 960

countries

Low- and 2.7 450 1 in 75 533,000

middle-income

Africa 4.8 820 1 in 26 276,000

Asia 2.3 330 1 in 120 241,000

Latin America 2.3 130 1 in 290 15,000

and Caribbean
Direct and indirect causes of maternal
mortality and morbidity

• Direct: related to pregnancy or

postpartum periods (hemorrhage
25%, sepsis 15%, eclampsia 12%,
complications of unsafe abortion
13%, obstructed labor and
others).
• Indirect: related to conditions
precede, but aggravated by,
pregnancy ( anemia, diabetes,
malaria, tuberculosis, cardiac
diseases, hepatitis, and
increasingly HIV) WHO,2005
Impact of reproductive patterns on
women health
Reproductive pattern Mechanism through which maternal health is affected

Number of pregnancies Each pregnancy carries a risk of morbidity and mortality

Higher-risk pregnancies

First-time mothers 2-4 higher risk for obstructed labor, induced hypertension, obstetric
complications due to initial adaptation
High-order pregnancies Hemorrhage and uterine rupture and reproductive injuries

Pregnancy at very young Physiological immature reproductive system and reduced timely
maternal ages care seeking.
Pregnancy at old maternal Body in poor condition for pregnancy and child birth
ages
Short interbirth intervals Inadequate time to rebuild nutritional stores and regain energy level.

Unwanted pregnancies Increased exposure to injuries, infections, hemorrhages, and deaths

ending in unsafe abortions
Pregnancy for women Aggravated health conditions.
already in poor health
Mechanisms to reduce maternal
morbidity and mortality.

• Reduced exposure to pregnancy by reducing

fertility (family planning).
• Optimization of access to emergency obstetric care
(assisted virginal delivery, removal of placenta,
using vacuum extraction or aspiration, anesthesia
and cesarean section, blood transfusion, ectopic
pregnancy and safe abortion….etc).
• Improvement of general health status and treatment
of pregnancy- and childbirth-related complications
(antenatal care, postnatal care, safe motherhood,
treatment of maternal illness….etc).
Conclusion

• Improvements are needed in the quality of family

planning services, especially in the areas of
information exchange and methods choice to
reduce fertility and unwanted pregnancy.
• Maternity care needs to be significantly expanded
to , while preventive services ( including education
of both men and women in health and sexuality,
family planning, and prevention of STIs) need to be
increased.
• At societal level, programs need to be supported to
improve the status of women through education,
changes in laws, and cultures.
Thank you for listening