Ambo university md Introduction to RH.pdf

Ambo university college of health and referral hospita department of midwifery 3 rd year 2nd semister by
Gurmesa

1. Reproductiveandmaternalhealth
Bikila
1

2. History, concepts, definitions, components of
RH
2

3. Session Objectives:-
Attheendofthelessonthestudentswillbeableto
➢ExplainhistoricaldevelopmentofRH
➢Definereproductivehealth
➢DescribefactorsinfluencingRh
➢Describereproductivehealthrights
➢Explainreproductivehealthindicators
➢Mentiontheglobalmentoringreproductivehealthindicators
3

4. Historical development of RH
✓Globalconcernaboutmaternalandchildhealthwasevidentassoon
astheWHOwasestablishedin1948.
✓TheprioritiesofWHOattheoutsetwasmaternalandchildhealth
alongsidetuberculosis,malariaandvenerealdiseases.
✓FollowingthisthePrimaryHealthCare(PHC)conference(HealthFor
Allbytheyear2000)madematernalandchildhealthcareasoneof
theeightelementsofPHCconsideringthatthehealthofmothersand
childrenhadnotimprovedinanymeaningfulway.
4

5. Cont’d
ElementsofPHC:-
❑Education
❑Waterandsanitation
❑Nutrition
❑Maternalandchildhealth
❑Immunization
❑Preventionendemicdisease
❑Treatment
❑Drugavailability
5

6. Cont’d
❖FollowingtheimplementationofthePHCstrategy,itwasnotedthat
improvementofmaternalhealthwasevengreatlydeficient.
❖Theworldwasfacedwithfactsaboutthetragedyofunacceptable
highmaternalmortality.
❖Someextraordinarycontributionsweremadeintheformof
publishedarticlesinthe1980sincluding“MaternalMortalitya
NeglectedTragedyWhereistheMinMCH?”.
❖Aglobalschemeknownas“SafeMotherhoodInitiative”was
introducedin1987.
❖TheprimaryaimoftheSafeMotherhoodinitiativewastoreduce
deathandillnessesamongwomenandinfantsindeveloping
countriesbyprovidingmaternalhealthservicestoallwomen.
6

7. Cont’d
TheInternationalConferenceonPopulationandDevelopmentICPD
(1994)andtheParadigmShift:-
DuringthetimeoftheICPDconference:-
▪Almost600,000womendiedeachyearduetopregnancy-related
causes,99%ofthemindevelopingcountries.
▪Lifetimeriskofmaternaldeathwasestimatedtobe1:48indeveloping
countrieswhereasitwas1:1800indevelopedones.
▪Therewereabout7-8millionperinataldeathseachyear.
▪Thereweremorethan330millioncasesofcurablesexuallytransmitted
diseasesworldwideeachyear.
7

8. Cont’d…
✓About60millioncoupleswereinfertileworldwide.
✓In1994,theInternationalConferenceonPopulationandDevelopment
(ICPD)inCairoapprovedanewProgramofActionasaguidefor
nationalandinternationalactionintheareaofpopulationand
developmentforthenext20years.
✓Theconferencecameupwithabigparadigmshiftfrompreviousworld
conferencesinitsstrategiestodealwithpopulationanddevelopment
basedonthelessonslearnedfrompreviousapproaches.
8

9. Cont’d…
Theshiftwasalsobasedonlessonslearnedfromthevariousprograms
thataimedatimprovingthehealthofmothersandchildrenovermany
decades.
Thisparadigmshiftwasexpressedinthefollowingways:
▪Shiftfrompopulationcontrolanddemographictargetstowardsamore
holisticapproachtowomen’shealth.
Realizationofthepossibilitytoachieveastabilizationofworld
populationgrowthwhileattendingtopeople’shealthneedsand
9

10. Cont’d
Recognitionoftheneedsofpeopleinsexualityandreproduction
beyondfertilityregulation.
Criticismoftheover-emphasisonthecontroloffemalefertility.
Radicalshiftawayfromtechnology-based,top-downapproachesto
programplanningandimplementation.
10

11. Cont’d
The1994ICPDhasbeenmarkedasthekeyeventinthehistoryof
reproductivehealth.
Theimpetusbehindtheparadigmshift:-
▪Thegrowingstrengthofthewomen’smovement.
▪TheadventoftheHIV/AIDSpandemic.
▪Aninterpretationofinternationalhumanrightstreatiesintermsof
women’shealthingeneralandreproductivehealthinparticular
graduallygainedacceptanceduringthe1990s.
11

12. Cont’d
ThePre-InternationalConferenceonPopulationand
Development(ICPD,m1994)period
ThefirstconferenceinRome(1954):-
❑Populationgrowthanditsconsequenceswereexpressedusingterms
suchas“standingroomonly”,“populationbombs”,“demographic
entrapment”andscarcityoffood,waterandrenewableresources.
ThesecondconferenceBelgrade:-
❑Emphasizedanalysisoffertilityaspartofapolicyfordevelopment
planningandcoincidedwiththestart-upofpopulationprograms
12

13. Cont’d
❑The1974Bucharest,Romaniastatedthatpopulationvariablesand
developmentareinterdependentandthatpopulationpoliciesand
theirobjectivesareanintegralpartofsocioeconomicdevelopment
policies.
❑ThenextworldpopulationconferencetookplaceinMexicoCityin
August1984.
❑Itreviewedandendorsedmostaspectsoftheagreementsofthe
1974BucharestconferenceandexpandedtheWorldPopulationPlan
ofAction.
13

14. cont’d
▪In1972,WHOestablishedtheSpecialProgramofResearch,
DevelopmentandResearchTraininginHumanReproduction
(HRP).
▪whosemandatewasfocusedonresearchintothedevelopment
ofnewandimprovedmethodsoffertilityregulationandissuesof
safetyandefficacyofexistingmethods.
14

15. The Post-Cairo Period
ProgressandchallengesinthefirstfiveyearsofimplementingtheCairoagreement
werethefocusofaseriesofmeetingsincludingaspecialsessionoftheUnited
NationsGeneralAssembly(ICPD+5)inJune1999.
FiveyearsafterICPDthesemainachievementsandchallengeswerethusidentified:
Achievements:-
Conceptadoptedbymostcountries.
Newpoliciesandprogramsdefined(e.g.,India’starget-freereproductiveandchild
healthprogram).
15

16. Cont’d
Newpartnershipsformed(e.g.,greaterNGO participation;
public/privatepartnerships).
Newevidencecollected(e.g.,burdenofdiseaseduetoreproductive
ill-health;bestpractices;gender-basedviolence).
Challenges:-
Patchyimplementationofholisticandintegratedprograms
Uncoordinated,fragmentedapproachesbymultipleplayers.
Failuretoscaleupfromprojectstosustainableprograms
16

17. Cont’d
Weakhealthsystems(healthsectorreform).
RelativeneglectofRHbynewdevelopmentinstruments(e.g.SWAPs,
PRSPs,GlobalFund,andothers.)and;
“Competition”from“other”programs.(e.g.,HIV/AIDS).
17

18. Cont’d
KeyActionstoCarryFurtherImplementationoftheProgramofAction
oftheICPDincludingsettingnewbenchmarkindicatorsofprogressin
fourkeyareas:
Educationandliteracy:-
▪Achievinguniversalaccesstoprimaryeducation;
▪eliminatethegendergapinprimaryandsecondaryeducationby
2005.
▪Primaryschoolenrolmentratio90%by2010forbothsex
▪Reducetherateofilliteracybyhalfby2005fromthe1990
18

19. Cont’d
Reproductivehealthcareandunmetneedforcontraception:-
▪Ensurethatby2015allprimaryhealthcareandfamilyplanning
facilitiesareabletoprovide,widestachievablerangeofsafeand
effectivefamilyplanning.
▪Provideessentialobstetriccare;preventionandmanagementof
reproductivetractinfections.
▪By2005,60percentofsuchfacilitiesshouldbeabletoofferthis
rangeofservices,andby2010,80percentofthemshouldbeableto
offersuchservices."
▪CPRandunmetneedby50percentby2005,75percentby2010
and100percentby2050.
19

20. Cont’d
Maternalmortalityreduction:-
▪Allbirthsshouldbeassessedbyskillbirthattendantby2005,80%,by
2010,85percent,andby2015,90percent."
▪Forcountrieswherematernalmortalityhigh40,50and60percent
respectively.
HIV/AIDS:-
▪youngmenandwomenaged15to24haveaccesstotheinformation,
educationandservicesnecessarytodevelopthelifeskillsrequiredto
reducetheirvulnerabilitytoHIVinfection.
▪90and95percentby2005and2010respectively
20

21. ICPD at 10
TheUNGeneralAssemblycommemoratedtheTenthAnniversaryof
ICPDinOctober2004
TheConferenceadmiredtheprogresswhileacknowledgingthe
challengethatmanycountriesmayfallshortofachievingtheagreed
upongoalsandthecommitmentsoftoitsProgramofActionby
reaffirmingtheProgramofActionoftheInternationalConferenceon
PopulationandDevelopmentandthecallingforkeymeasurestobe
implementedfurther.
21

22. Cont’d
Inthesameway,Africanministersresponsibleforpopulationand
development,whometinDakar,Senegal,on11June2004,welcomed
withsatisfactiontheten-yearreviewofICPDPOA,pointedoutthe
constraintsencounteredandshowedthewayforward.
Theyreaffirmedtheneedtoachievegenderequality,equityandthe
empowermentofwomenashighlyimportantendsinthemselvesandkey
tobreakingthecycleofpovertyandimprovingthequalityoflifeofthe
peopleofthecontinent.
22

23. Cont’d
AchievingtheMDGGoalsby2014andBeyond
Thereviewfoundthecommitmentofgovernments,UNand
othersstakeholdersappreciableandprogressivesinceICPD.
Italsoidentifiedgapsthatneededtobetakencareofandmade
suggestionsforimprovementintheseareas:-
❑EradicatingPoverty
❑GenderEquality:
❑Massiveviolationofhumanrightsofwomenandgirls
23

24. Development of reproductive health
Before1978Alma-AtaConference
Basichealthservicesinclinicsandhealthcenters
Primaryhealthcaredeclaration1978
MCHservicesstartedwithmoreemphasisonchildsurvival
Familyplanningwasthemainfocusformothers
24

25. Cont’d
Safemotherhoodinitiativein1987
Emphasisonmaternalhealth
Emphasisonreductionofmaternalmortality
Reproductivehealth,ICPDin1994
Emphasisonqualityofservices
Emphasisonavailabilityandaccessibility
Emphasisonsocialinjustice
Emphasisonindividualswoman'sneedsandrights
25

26. cont’d
Millenniumdevelopmentgoalsandreproductivehealthin
2000
MDGsaredirectlyorindirectlyrelatedtohealth
MDG4,5and6aredirectlyrelatedtohealth,whileMDG1,2,3,
and7areindirectlyrelatedtohealth
WorldSummit2005,declareduniversalaccesstoreproductive
health
26

27. Cont’d
Goal3:PromoteGenderEqualityandEmpowerWomen
Target3.A:Eliminategenderdisparityinprimaryandsecondary
enrolment,preferablyby2005,andinalllevelsofeducationnolater
than2015.
Indicator3.1:Ratiosofgirlstoboysinprimary,secondaryandtertiary
education.
Indicator3.2:Shareofwomeninwageemploymentinthenon-
agriculturalsectors.
27

28. Cont’d
Goal4:Reducechildmortality
Target4.A:Reducebytwo-thirds,between1990and2015,theunder-
fivemortalityrate.
Indicator4.1:under-fivemortalityrate.
Indicator4.2:infantmortalityrate.
Indicator4.3:proportionof1year-oldchildrenimmunizedagainst
measles.
28

29. Cont’d
Goal5:Improvematernalhealth
Target5.A:Reducebythreequarters,between1990and2015,thematernalmortality
ratio
Indicator5.1:Maternalmortalityratio
Indicator5.2:Proportionofbirthsattendedbyskilledhealthpersonnel
Target5.B:Achieve,by2015,universalaccesstoreproductivehealth
Indicator5.3:Contraceptiveprevalencerate
Indicator5.4:AdolescentbirthrateIndictor
5.5:Antenatalcarecoverage(atleastonevisitandatleastfourvisits)
Indicator5.6:Unmetneedforfamilyplanning
29

30. Cont’d
Goal6:CombatHIV/AIDS,malariaandotherdiseases
Target6.A:Havehaltedby2015andbeguntoreversethespreadof
HIV/AIDS
Indicator6.1:HIVprevalenceamongpopulationaged15-24years
Indicator6.2:Condomuseatlasthigh-risksex
Indicator6.3:Proportionofpopulationaged15-24yearswith
30

31. Cont’d
FollowingtheMGD’sthesustainabledevelopmentgoalsappears
Thesustainabledevelopmentgoals(SDGs)areanew,universalsetof
goals,targetsandindicatorsthatUNmemberstateswillbeexpected
tousetoframetheiragendasandpoliticalpoliciesoverthenext15
years.
Whyweneedothergoals???
31

32. Cont’d
Whydoweneedanothersetofgoals?
MDGsweretoonarrow.
TheeightMDGs–failedtoconsidertherootcausesofpovertyand
overlookedgenderinequalityaswellastheholisticnatureofdevelopment.
32

33. Cont’d
▪Thegoalsmadenomentionofhumanrightsanddidnotspecifically
addresseconomicdevelopment
▪WhiletheMDGs,intheory,appliedtoallcountries,inrealitytheywere
consideredtargetsforpoorcountriestoachieve,withfinancefromwealthy
states.
▪AstheMDGdeadlineapproaches,about1billionpeoplestillliveonlessthan
$1.25aday
▪TheWorldBankmeasureonpoverty–andmorethan800millionpeopledonot
haveenoughfoodtoeat.
▪Womenarestillfightinghardfortheirrights,andmillionsofwomenstilldiein
childbirth.
33

34. Cont’d
Whataretheproposed17goals?
1)Endpovertyinallitsformseverywhere
2)Endhunger,achievefoodsecurityandimprovednutrition,andpromote
sustainableagriculture
3)Ensurehealthylivesandpromotewellbeingforallatallages
4)Ensureinclusiveandequitablequalityeducationandpromotelifelong
learningopportunitiesforall
5)Achievegenderequalityandempowerallwomenandgirls
6)Ensureavailabilityandsustainablemanagementofwaterandsanitation
forall
34

35. Cont’d
10)Reduceinequalitywithinandamongcountries
11)Makecitiesandhumansettlementsinclusive,safe,resilientand
sustainable
12)Ensuresustainableconsumptionandproductionpatterns
13)Takeurgentactiontocombatclimatechangeanditsimpacts(taking
noteofagreementsmadebytheUNFCCCforum)
14)Conserveandsustainablyusetheoceans,seasandmarineresources
forsustainabledevelopment
15)Protect,restoreandpromotesustainableuseofterrestrialecosystems,
sustainablymanageforests,combatdesertificationandhaltandreverse
35

36. Cont’d
16)Promotepeacefulandinclusivesocietiesforsustainabledevelopment,
provideaccesstojusticeforallandbuildeffective,accountableand
inclusiveinstitutionsatalllevels
17)Strengthenthemeansofimplementationandrevitalizetheglobal
partnershipforsustainabledevelopment
36

37. Definition of Reproductive Health
ICPD(1994)definedReproductiveHealthasastateofcompletephysicalmentalandsocial
wellbeingandnotmerelytheabsenceofdiseaseorinfirmity,inallmattersrelatedtothe
reproductivesystemanditsfunctionsandprocesses.
Thisdefinitionimplies:-
➢Peopleareabletohaveasatisfyingandsafesex.
➢Thecapabilitytoreproduceandthefreedomtodecideif,whenandhowoftentodoso.
➢Therightofmenandwomentobeinformedofandtohaveaccesstosafe,effective,
affordableandacceptablemethodsoffamilyplanningoftheirchoice,aswellasother
methodsoftheirchoiceforregulationoffertility37

38. Cont’d
Thethreefundamentalprinciplesofsexualhealthare:
1)Capacitytoenjoyandcontrolsexualandreproductivebehavior
2)Freedomfromshame,guilt,fear,andotherpsychologicalfactorsthatmay
impairsexualrelationships;and
3)Freedomfromorganicdisorderordiseasethatinterfereswithsexualand
reproductivefunction.
38

39. Cont’d
▪Sexualhealthistheintegrationofemotional,intellectual,andsocial
aspectsofsexualbeinginordertopositivelyenrichpersonality,
communication,relationshipsandlove.
▪Reproductivehealthcontributesenormouslytophysicaland
psychosocialcomfortandclosenessbetweenindividuals.
▪Poorreproductivehealthisfrequentlyassociatedwithdisease,abuse,
exploitation,unwantedpregnancy,anddeath.39

40. Cont’d
▪Healthysexualityisavitalcomponentofreproductivehealth
▪Everysexactshouldbefreeofcoercionandinfection.
▪Everypregnancyshouldbeintendedandeverybirthhealthy.
▪Healthysexualityshouldincludetheconceptofvolitionandinformed
decision-making.
40

41. Reproductive Health Care
Reproductivehealthcareisdefinedastheconstellationofmethods,
techniquesandservicesthatcontributetoreproductivehealthand
wellbeingbypreventingandsolvingreproductivehealthproblems.
ObjectivesofReproductiveHealthCare
(a)Toensurethatcomprehensiveandfactualinformationandafull
rangeofreproductivehealthcareservices,includingfamilyplanning,are
accessible,affordable,acceptableandconvenienttoallusers.
41

42. Cont’d
(b)Toenableandsupportresponsiblevoluntarydecisionsbypeopleabout
childbearingandmethodsoffamilyplanningoftheirchoice,aswellas
othermethodsoftheirchoiceforregulationoffertilitywhicharenot
againstthelawandtohavetheinformation,.educationandmeanstodo
so
(c)Tomeetchangingreproductivehealthneedsoverthelifecycleandto
dosoinwayssensitivetothediversityofcircumstancesoflocal
communities
42

43. Components of Reproductive Health Care
Inthecontextofprimaryhealthcare,reproductivehealthcareconsistsof
atleastthefollowingcomponents:
❖Family-planningcounselling,information,education,communicationand
services.
❖Educationandservicesforprenatalcare,safedeliveryandpost-natal
care,especiallybreast-feedingandinfantandwomen'shealthcare.
43

44. Cont’d
❖Preventionandappropriatetreatmentofinfertility
❖Preventabortionandthemanagementoftheconsequencesofabortion;
treatmentofRTI;STDandotherreproductivehealthconditions.
❖Safeabortionserviceswherenotagainstthelaw
❖Information,educationandcounseling,asappropriate,concerning
sexuality,reproductivehealthandresponsibleparenthood.
44

45. Cont’d
❖Referralforfamilyplanningservicesandfurtherdiagnosisand
treatmentforcomplicationsofpregnancy,delivery,abortion,infertility,
reproductivetractinfections,breastcancerandcancersofthe
reproductivesystem,sexuallytransmitteddiseases,includingHIV/AIDS
shouldalwaysbeavailable,asrequired.
❖Activediscouragementofharmfulpractices,likefemalegenital
mutilation,shouldalsobeanintegralpartofprimaryhealthcare,aswell
asincludingreproductivehealthcareprograms
45

46. Enabling Conditions for RH
TheInternationalConferenceonPopulationandDevelopment
(ICPD1994)identifiedthefollowingenablingconditionsfor
reproductivehealth:-
EmpoweringWomenandPromotingGenderEqualityandEquity:-
Thegoalshouldbetoeliminateallformsofdiscriminationagainstwomeninorderfor
themtoexercisetheirrightstosexualandreproductivehealthandparticipateequallyat
alllevelsofpoliticalandpubliclife.
EliminatingDiscriminationagainsttheGirlChild:
Allformsofdiscriminationagainstthegirlchildandthereasonsforcausesofson
preferences,whichresultinharmfulandunethicalpracticesregardingfemale
infanticideandparentalsexselectionshouldbeeliminated.
46

47. Cont’d
EnsuringMaleResponsibilityandParticipation:
Menplayakeyroleintheachievementofgenderequalitybecause,inmostsocieties,
theirpowerissupremeinalmostallspheresoflife.
AchievingUniversalEducation:-
Progressineducationcontributestoreductioninfertility,morbidityandmortality;the
empowermentofwomen;improvementinthequalityoflife;andthepromotionofgenuine
democracyandrespectfor,andtheexercise,humanrightsandfundamentalfreedoms.
Increasinglytheeducationofgirlsandwomenleadstothepostponementoftheageat
marriage,reductioninfamilysize,andchildsurvival47

48. Cont’d
Inadditiontheattainmentofreproductivehealthbypopulations
requires:
❑Anenablingenvironment-politically,legallyandculturally;
❑Theempowermentofindividualswithknowledgeonhowtopromote
andprotecttheirownreproductivehealth;
❑Theprovisionofawide-rangeofhighqualityhealthservices-
accessible,appropriate,affordableandeffective.
48

49. Factors affecting reproductive health
Reproductivehealthaffects,andisaffectedby,thebroadercontextof
people'slives,including:-
❑Economiccircumstances
❑Education
❑Employment
❑livingconditionsandfamilyenvironment
❑Socialandgenderrelationships,and
❑ThetraditionalandlegalStructureswithinwhichtheylive.
49

50. Cont’d
❑Sexualandreproductivebehaviorsaregovernedbycomplex
biological,culturalandpsychosocialfactors.
❑Therefore,theattainmentofreproductivehealthisnotlimitedto
interventionsbythehealthsectoralone.
❑Nonetheless,mostreproductivehealthproblemscannotbe
significantlyaddressedintheabsenceofhealthservicesand
medicalknowledgeandskills.
50

51. The importance of reproductive health
➢Reproductivehealthisacrucialpartofgeneralhealthandacentral
featureofhumandevelopment.
➢Itisareflectionofhealthduringchildhood,andcrucialduring
adolescenceandadulthood,setsthestageforhealthbeyondthe
reproductiveyearsforbothwomenandmen,andaffectsthehealth
ofthenextgeneration
51

52. Cont’d
➢Reproductivehealthisauniversalconcern,butisofspecialimportance
forwomenparticularlyduringthereproductiveyears.
➢Althoughmostreproductivehealthproblemsariseduringthe
reproductiveyears,inoldagegeneralhealthcontinuestoreflectearlier
reproductivelifeevents
➢Ateachstageoflifeindividualneedsdiffer.However,thereisa
cumulativeeffectacrossthelifecourseþeventsateachphasehaving
importantimplicationsforfuturewell-being.
52

53. Cont’d
➢Failuretodealwithreproductivehealthproblemsatanystageinlifesets
thesceneforlaterhealthanddevelopmentalproblems.
➢Becausereproductivehealthissuchanimportantcomponentofgeneral
healthitisaprerequisiteforsocial,economicandhumandevelopment.
➢Thehighestattainablelevelofhealthisnotonlyafundamentalhuman
rightforall,itisalsoasocialandeconomicimperativebecausehuman
energyandcreativityarethedrivingforcesofdevelopment.
53

54. Human Rights and Reproductive Rights
Reproductiverightsembracecertainhumanrightsrecognizedin
nationalandinternationallegalandhumanrightsdocuments.
Someexamplesoftheapplicationofhumanrightstoreproductive
health
1.Righttolife:
promotesafemotherhoodandadvocateagainstmaternalmortalityand
morbidity,infanticide,genocide,andviolence.
2.TherighttoLibertyandSecurityofthePerson:
protectionofwomenandchildrenfromsexualabuseandsuchpractices
asfemalegenitalmutilation
54

55. Cont’d
3.Righttobefreefromallformsofdiscrimination:
➢Discriminationwithregardtoaccesstosexualandreproductive
healthservices
➢Discriminationthatdenieslegalprotectionagainstviolence.
➢Campaignforlawsprohibitingdiscriminationagainstwomenand
workfortheireffectiveenforcement.
55

56. Cont’d
4.Righttoinformationandeducation:
➢Allowtheyouthhavingaccesstoinformationandeducation
➢Giveaccurateinformationtoenableserviceuserstomakedecisions
onthebasisoffull,free,andinformedconsent
➢Discourageprogramswhichdonotgivefullinformationontherelative
benefits,risks,andeffectivenessofallmethodsoffertilityregulation.
56

57. Cont’d
5.RighttobefreefromtortureandillTreatment:
➢Protectwomenandchildrenfromsexualexploitation,prostitution
➢Protectwomenandchildrenfromsexualabuse,coercioninany
sexualactivity,anddomesticviolence
➢Amendlegislationwhichprohibitsabortiononthegroundsofrape.
57

58. Cont’d
6.Therighttoprivacy:
➢Allsexualandreproductivehealthcareservicesshouldbeconfidential.
7.Therighttofreedomofthought:
➢Freedomfromtherestrictiveinterpretationofreligioustexts,beliefs,
philosophiesandcustomsastoolstocurtailfreedomofthoughtabout
sexualandreproductivehealthcare.
58

59. Cont’d
TheInternationalPlannedParenthoodFederation(IPPF)inadditiontotheabove
rightsincludesthefollowingasasexualandReproductiverights:-
TheRighttoChooseWhetherorNottoMarryandtoFoundandPlanaFamily:-
➢Recognizesthatallpersonshavetherighttoprotectionagainstarequirementto
marrywithoutthatperson’sfull,freeandinformedconsent.
TheRighttoHealthCareandHealthProtection:-
➢Includestherightofhealthcareclientstothehighestpossiblequalityofhealthcare,
andtherighttobefreefromtraditionalpracticeswhichareharmfultohealth.
59

60. Cont’d
TheRighttoDecideWhetherorWhentoHaveChildren:-
➢Recognizesthatallpersonshavetherighttodecidefreelyand
responsiblythenumberandspacingoftheirchildrenandtohave
accesstotheinformation,educationandmeanstoenablethemto
exercisethisrightandfurtherrecognizesthatspecialprotection
shouldbeaccordedtowomenduringareasonableperiodbefore
andafterchildbirth.
60

61. Cont’d
TheRighttotheBenefitsofScientificProgress:-
➢Includestherightofsexualandreproductivehealthserviceclientstonew
reproductivehealthtechnologiesthataresafe,effectiveandacceptable.
TheRighttoFreedomofAssembly&PoliticalParticipation:-
➢Includestherightofallpersonstoseektoinfluencecommunitiesandgovernmentsto
prioritizesexualandreproductivehealthandrights
61

62. The life cycle approach of Reproductive health
THELIFECYCLEPERSPECTIVE
Reproductivehealthisimportantforhealthysocial,economic,and
humandevelopment!
oReproductivehealthisacrucialfeatureofhealthyhuman
developmentandofgeneralhealth.
oItmaybeareflectionofahealthychildhood,iscrucialduring
adolescence,andsetsthestageforhealthinadulthoodandbeyond
thereproductiveyearsforbothmenandwomen.
62

63. Cont’d
oReproductivelifespandoesnotbeginwithsexualdevelopmentatpubertyandendat
menopauseforawomanorwhenamanisnolongerlikelytohavechildren.
oRather,itfollowsthroughoutanindividual’slifecycleandremainsimportantinmany
differentphasesofdevelopmentandmaturation.
oAteachstageoflife,individualreproductivehealthneedsmaydiffer.
oHowever,thereisacumulativeeffectacrossthelifecourse,andeachphasehas
importantimplicationsforfuturewell-being.
oAninabilitytodealwithreproductivehealthproblemsatanystageinlifemaysetthe
sceneforlaterhealthproblems.Thisisknownasthelifecycleperspectivefor
reproductivehealth.
63

64. Cont’d
Reproductivehealthisalifetimeconcernforwomenandmen,frominfancytooldage.
Inmanycultures,discriminationagainstgirlsandwomenthatbeginsininfancycan
determinethetrajectoryoftheirlives.
CriticalMessagesforDifferentLifeStagesthatcanempowermenandwomen:-
GirlsandBoys
✓Delaypregnancy
✓Inspireandmotivationtobesexuallyresponsiblepartner
✓Responsibilityforthehumancatastropheoforphansandotherchildrenwholiveinthe
streets
64

65. Cont’d
Adolescents:-
✓Integratedreproductivehealtheducationandservicesforyoung
peopleshouldincludefamilyplanninginformation,andcounseling
ongenderrelations,STDsandHIV/AIDS,sexualabuseand
reproductivehealth.
✓Ensurethathealthcareprogramsandserviceproviders'attitudes
allowforadolescents'accesstothespecialservicesandinformation
theyneed.65

66. Cont’d
✓Supporteffortstoeradicatefemalegenitalcuttingandotherharmful
practices,likeearlyorforcedmarriage,sexualabuse,andtraffickingof
adolescentsforforcedlabor,marriageorcommercialsex.
✓Socializeandmotivateboysandyoungmentoshowrespectand
responsibilityintheirsexualrelations.
66

67. Cont’d
Adults:-
✓Improvecommunicationonissuesofsexualityandreproductivehealth,andthe
understandingoftheirjointresponsibilitiessothattheyareequalpartnersinpublic
andprivatelife.
✓Enablewomentoexercisetheirrighttocontroltheirownfertilityandtheirrightto
makedecisionsconcerningreproduction
✓Improvethequalityandavailabilityofreproductivehealthcareservicesand
barrierstoaccess.
67

68. Cont’d
✓Makeemergencyobstetriccareavailabletoallwomenwhoexperience
complicationsintheirpregnancies.
✓Encouragemen'sresponsibilityforsexualandreproductivebehavior
andincreasemaleparticipationinfamilyplanning.
68

69. Cont’d
TheOlderYears:-
✓Reorientandstrengthenhealthcareservicestobettermeettheneedsofolderwomen.
✓Supportoutreachbywomen'sNGOstohelpolderwomeninthecommunitytobetter
understandtheimportanceofgirls'education,theirreproductiverightsandsexual
healthsothattheymaybecomeeffectivetransmittersofsuchknowledgeandpractices.
✓Developstrategiestobettermeettheneedsoftheelderlyforfood,water,shelter,
socialandlegalservicesandhealthcare
69

70. Reproductive health indicators
▪Ahealthindicatorisusuallyanumericalmeasurewhichprovidesinformationabouta
complexsituationorevent.
▪Indicatorsaremarkersofhealthstatus,serviceprovisionorresourceavailability,
designedtoenablethemonitoringofserviceperformanceorprogramgoals.
▪Anindicatorisaspecific,observableandmeasurablecharacteristicthatcanbeused
toshowchangesorprogressaprogramismakingtowardachievingaspecific
outcome.
▪Indicatorsareexpressedintermsofrates,proportions,averages,categorical
variablesorabsolutenumbers.
70

71. Cont’d
▪Theycanbeusefultoolsforassessingneeds,monitoringandevaluatingprogram
implementationandimpact
▪Needsassessment:toassessthecurrentstatusofreproductivehealthinthepopulation
orinaspecificsub-group
▪Monitoring:tomonitortheimplementationandoutputsofaprogramtoensureitison-
track,ortomonitorpolicycommitment
▪Evaluation:toevaluatetheeffectivenessandimpactofaprogramaimedatimproving
reproductivehealthand/orachievingspecifictargets
71

72. Cont’d
TheWHOdistinguishesthreedimensionsofreproductivehealth:
Asahumancondition(includingthelevelofhealthandrelatedareasof
wellbeing)
Asanapproach(policies,legislationandattitudes);
Andasservices(theprovisionofservices,accesstothem,andtheirutilization).
72

73. Cont’d
Thereareseveralindicatortomeasurereproductivehealthindicators
selectedbydifferentcriteria.
Theselectioncriteriaforindicatorsbybeing:-
➢Ethical
➢Useful
➢Scientificallyrobust
➢Representative
➢Understandable,and
➢Accessible
73

74. Key performance information concepts for M & E

74

75. 75
Cont’d
Long-
term Goal
(Impact) Outcomes
Long-term,
widespread
improveme
nt in
society
behavior
changes
resulting
from
program
outputs
Outputs Activities Inputs
Products
and services
to be used
to simulate
the
achievemen
t of results
Utilization
of resources
to generate
products
and services
Resources
committed
to
program
activities
Results Implementation
PLANING FOR RESULTS
Results-based M&E

76. 76
Cont’d

77. 77
Cont’d

78. Cont’d
WHOexpertsidentifiedashortlistofindicatorsformonitoring
reproductivehealthatnationalandinternationallevels.Themost
widelyusedonesaredefinedbelow:-
1.TotalFertilityRate:
➢Totalnumberofchildrenawomanwouldhavebytheendofher
reproductiveperiod,ifsheexperiencedthecurrentlyprevailing
age-specificfertilityratesthroughoutherchildbearinglife.
78

79. Cont’d
➢Itiscloselyassociatedwithcontraceptiveprevalenceandother
indicatorsofreproductivehealthsuchasthematernalmortality
ratio.
➢Itisausefulindicatorofpopulationmomentumandagood
proxymeasureforthesuccess(orfailure)offamilyplanning
services.
➢TheTFRmayalsobeusedasameasureofpoorphysical
reproductivehealth,sincehighparity(>5births)representsa
79

80. Cont’d
2.ContraceptivePrevalence:
➢Thepercentageofwomenofreproductiveagewhoareusing(or
whosepartnerisusing)acontraceptivemethodataparticularpointin
time.
➢Thisindicatorisusefulformeasuringutilizationofcontraceptive
methods
80

81. Cont’d
3.MaternalMortalityRatio:
Thenumberofmaternaldeathsper100000livebirthsfromcauses
associatedwithpregnancyandchildbirth.
▪Maternalmortalityiswidelyacknowledgedasageneralindicatorof
theoverallhealthofapopulation,ofthestatusofwomeninsocietyand
ofthefunctioningofthehealthsystem.
81

82. Cont’d
▪Itisthereforeusefulforadvocacypurposes,intermsbothofdrawing
attentiontobroaderchallengesfacedbygovernmentsandofsafe
motherhood.
▪Thisindicatorcanshowthemagnitudeoftheproblemofmaternal
deathinacountryasastimulusforaction.
82

83. Cont’d
4.AntenatalCareCoverage:
➢Thepercentageofwomenattended,atleastonceduringpregnancy,byskilled
healthpersonnelforreasonsrelatedtopregnancy.
➢Themainpurposeofanindicatorofantenatalcare1-visitcoverageistoprovide
informationonproportionofwomenwhouseantenatalcareservices.
➢ThefindingthatwomenwhoattendANCarealsomorelikelytouseskilledhealth
personnelforcareduringbirthandthatANCmayfacilitatebetteruseof
emergencyobstetricservicesisalsofurthersupportfortheuseofthisindicatorin
combinationwiththeindicator“skilledattendantatdelivery”.
83

84. Cont’d
5.BirthsAttendedbyASkilledHealthPersonnel:
➢Thepercentageofbirthsattendedbyskilledhealthpersonnel.This
doesn’tincludebirthsattendedbytraditionalbirthattendants.
➢Bothbirthsattendedbyskilledpersonnelandantenatalcarecoverage
aremeasuresofhealthcareutilization;theyprovideinformationon
actualcoverage(theeffectivepopulationthatreceivesthecare).
84

85. Cont’d
➢Theindicatorhelpsprogrammanagementatdistrict,nationaland
internationallevelsbyindicatingwhethersafemotherhoodprograms
areontargetintheavailabilityandutilizationofprofessional
assistanceatdelivery.
➢Inaddition,theproportionofbirthsattendedbyskilledpersonnelisa
measureofthehealthsystem’sfunctioningandpotentialtoprovide
adequatecoveragefordeliveries.
85

86. Cont’d
6.AvailabilityofBasicEssentialObstetricCare:
Thenumberoffacilitieswithfunctioningbasicessentialobstetriccare
per500000population.
7.AvailabilityofComprehensiveEssentialObstetricCare:
Thenumberoffacilitieswithfunctioningcomprehensiveessential
obstetriccareper500000population.
86

87. 87
cont’d
TheoreticalpathwayassociatingtheavailabilityofEOCserviceswithmaternal
mortality:-
Informati
on about
services
Motivatio
n to seek
care
Money
Time
Transpor
tation
Availabili
ty of
services
Timel
y use
of
good-
qualit
y
servic
es
Appropriat
e
manageme
nt of life-
threatening
obstetric
conditions
Reductio
n in
maternal
mortality

88. Cont’d
8.PerinatalMortalityRate:
➢Thenumberofperinataldeaths(deathsoccurringduringlate
pregnancy,duringchildbirthanduptosevencompleteddaysoflife)per
1000totalbirths.
➢Perinatalmortalityisassociatedwithpoormaternalhealth.
➢Itprovidesusefulinsightintothequalityofintrapartumandimmediate
postnatalcareandmaybeusedasagoodproxymeasureofthequality
88

89. Cont’d
Ithasbeensuggestedasanalternativeandmoresensitivemeasureof
maternalhealthstatus,sincetheascertainmentofperinataldeathisless
difficultthanthatofmaternalmorbidity.
9.LowBirthWeightPrevalence:
Thepercentageoflivebirthsthatweighlessthan2500g.
89

90. Cont’d
➢Althoughdurationofpregnancyisthemostimportantdeterminantof
weightatbirth,manyotherfactorscontribute.
➢TherateofLBWisaroughsummarymeasureofmanyfactors,
includingmaternalnutrition(duringchildhood,adolescence,pre-
pregnancyandpregnancy),lifestyle(e.g.alcohol,tobaccoanddrug
use)andotherexposuresinpregnancy(e.g.infectiousdiseasesand
altitude)
➢LBWisstronglyassociatedwitharangeofadversehealthoutcomes,
suchasperinatalmortalityandmorbidity,infantmortality,disability
anddiseaseinlaterlife.
90

91. Cont’d
10.PositiveSyphilisSerologyPrevalenceinPregnantWomen;
➢Thepercentageofpregnantwomen(15–24)attendingantenatalclinics,
whosebloodhasbeenscreenedforsyphilis,withpositiveserologyfor
syphilis.
➢Atthenationalandinternationallevels,thisindicatorisusefulasaproxy
oftheburdenofsexuallytransmittedinfections(STI)inthegeneral
population,andalsoasamarkerofprogresstowardsreducingthe
burdenofSTI.
91

92. Cont’d
11.PrevalenceofAnemiainWomen:
➢Thepercentageofwomenofreproductiveage(15–49)screenedfor
hemoglobinlevelswithlevelsbelow110g/lforpregnantwomenand
below120g/lfornon-pregnantwomen.
➢Itcanbeusedasaproxymeasureofgeneralnutritionalstatusorasa
directmeasureofhealthstatus,sinceanemiaisdirectlyinjuriousto
healthandisanimportantcontributortomorbidityandmortality.
92

93. Cont’d
12.PercentageofObstetricandGynecologicalAdmissionsowingtoAbortion:
➢Thepercentageofallcasesadmittedtoservicedeliverypointsprovidingin-
patientobstetricandgynecologicalservices,whichareduetoabortion
(spontaneousandinduced,butexcludingplannedterminationofpregnancy).
➢Thisindicatorcanbeusedtodescribeconditionsatonepointintimeonly.
➢Thebestuseoftheindicatorisasameasureofcase-load(orcostorresource
demand)imposedonthemedicalsystembycomplicationsofabortion.Itcan
beconceivedasaprocessindicatorformeasuringutilizationofservicesin
casesofabortioncomplications.
93

94. Cont’d
13.ReportedPrevalenceofWomenwithFGM:
Thepercentageofwomeninterviewedinacommunitysurvey,and
reportingtohaveundergoneFGM.
FGMhasadirectinjuriouseffectonreproductivehealth.
Reducingitsprevalenceisthusamarkerofprogresstowardsimproved
reproductivehealth.
94

95. Cont’d
14.PrevalenceofInfertilityinWomen:
➢Thepercentageofwomenofreproductiveage(15–49)atriskof
pregnancy(notpregnant,sexuallyactive,non-contraceptionandnon-
lactating)whoreporttryingforapregnancyfortwoyearsormore.
➢Whileinfertilityanditsemotionalandsocialconsequencescanhavea
seriousnegativeeffectonreproductivehealthstatus,appropriate
treatmentmaybeunavailableorexpensive.
➢EffectivesafemotherhoodandSTIpreventionprogramscan
significantlyreducesecondaryinfertility.
95

96. Cont’d
15.ReportedIncidenceofUrethritisinMen:
➢Thepercentageofmen(15–49)interviewedinacommunitysurvey,
andreportingatleastoneepisodeofurethritisinthelast12months.
➢Thisindicatorisusefulasameasureoftheimpactofpreventive
servicesforsexuallytransmittedinfections(STI).Italsoprovidesan
indicationoftheperceivedburdenofSTIontheadultmalepopulation,
asitmeasuresthereportedprevalenceofamajorSTIsymptomin
men.
➢Urethritisisdischargefromthepenis,withorwithoutaburning
sensationorpainwhilepassingurine.
96

97. Cont’d
16.HIVPrevalenceinPregnantWomen:
➢Thepercentageofpregnantwomen(15–24)attendingantenatalclinics,
whosebloodhasbeenscreenedforHIV,andwhoaresero-positivefor
HIV.
➢ThisindicatorisusedasaproxyforHIVincidence.
➢TheincidenceofHIVinfectionisthepreferredindicatortomonitorthe
courseoftheHIVepidemicandtheimpactofinterventions;prevalence
dataareoflimitedvaluesincetheyreflectinfectionsacquiredovera
numberofyears.
➢Inthecaseofthisindicator,incidenceisestimatedfromprevalencedata
inyoungwomen;prevalenceinthisagegroupislikelytoreflect
infectionsthathaveoccurredrecently.
97

98. Cont’d
17.KnowledgeofHIV-relatedPreventionPractices:
➢Thepercentageofallrespondentswhocorrectlyidentifyallthreemajorwaysof
preventingthesexualtransmissionofHIVandwhorejectthethreemajor
misconceptionsaboutHIVtransmissionorprevention.
➢KnowledgeofpreventivepracticesinHIV/AIDSisaprerequisiteforbehavioralchange.
Originally,theindicatorconsistedonlyincorrectlyidentifyingHIVprevention
practices,withtheunderlyingrationalethatimprovedknowledgeofsuchpracticesisa
preconditiontoconstructivebehavioralchange.
98

99. Reproductive Health in Ethiopia
▪AlthoughEthiopiahasdesignedandimplementedvariouspolicies
andstrategiesandprogramsandimprovementshavebeennoted.
▪Deathsfromreproductivehealthassociatedcausesarehighas
evidencedbyhighmaternalandinfantmortalityandmorbidity
rates.
▪Reproductivehealthstatusisdeterminedbypooreconomicstatus
(poverty),educationalstatus(particularlythatofwomenandgirls),
thelegalenvironment,provisionofhealthcare(RHstrategy
document).
99

100. Cont’d
▪Reproductivehealthservicecoverageremainslowalthoughthere
havebeenconsiderableimprovementsinutilizationofsomeservices
likefamilyplanning.
▪Women’sstatusbothinthecommunityandinthehouseholdislow,
constrainedbyapatriarchalfamilysystemdominatedbymenandby
elders.
▪Genderdiscriminationstartsfrombirthanddecisionmakinginthe
householdisdominatedbymales
100

101. Cont’d
▪Researchhasshownthatwomen’seducationdelaysmarriageandfirstbirth,
increasesFPuse,improvescommunicationwithpartnersandadvances
women’sstatusinthecommunity.
▪Althoughgirls’enrollmentinschoolhasincreasedsignificantly,itstillfallswell
behindthatofboys;andgirlsaresignificantlylesslikelythanboystocontinue
theirschoolingtohighschoolcompletion.
▪Employmentinpaidjobsintheformaleconomyissignificantlylowerfor
womenthanmen.
▪Finally,exposuretothemedia,whilegenerallylow,issignificantlylowerfor
women,providinglessopportunityforaccesstoinformationthatmightbe
useful.
101

102. RH Indicators in Ethiopia
Indicators
✓Totalfertilityrate-------------------------------------------4.6
✓Contraceptiveprevalentrateanymodernmethod-----41%
✓Contraceptiveprevalentratemodern------------------35%
✓Maternalmortalityration---------------------------------412/100,000
✓Antenatalcarebyaskilledprovider---------------------74%
✓Birthattendedbyskilledpersonal-----------------------48%
✓Adolescentbirthrate----------------------------------------13%
✓neonatalmortality-------------------------------------------30
✓Infantmortality------------------------------------------------43
✓Underfivemortality-------------------------------------------55
102

103. Cont’d
▪Overthepast20years,thegovernmentofEthiopiahasfollowedup
onitsinternationalcommitmentsbyadoptingandimplementinga
seriesofpoliciesandnationalstrategies
▪aimedatcreatingthenecessaryconditionsforallEthiopianstohave
accesstobasicsocialservicesaswellasensuringwomen’shuman,
economic,andpoliticalrightsandtheirfullparticipationinthe
developmentprocess.
103

104. cont’d
Globalandnationalpolicyenvironment
TheEthiopianGovernmentisasignatorytoseveralInternational
Conventions/ChartersandDeclarationsincludingthosearising
from:-
•SafeMotherhoodConferenceinNairobiin1987;
•WorldSummitforChildrenin1990;
•InternationalConferenceonPopulationandDevelopment(ICPD)in
1994
•(FPisoneoftheeightICPDpriorityactions)
104

105. Cont’d
▪FourthWorldConferenceforWomenin1995;
▪ConventiononEliminationofallformsofDiscriminationagainst
Women(CEDAW);
▪MillenniumDeclaration
▪TheUNHumanRightsCharter
▪DeclarationontheEliminationofViolenceAgainstWomen
(DEVAW).
105

106. Cont’d
StrategiesrelatedtoRH:-
1.Strengthenandexpandcommunityandfacility-basedmaternal,
newborn,childandadolescenthealthservices.
1.1.Scaleupfamilyplanningprogram(throughcommunitybasedFP
services,socialmarketing,facilitybasedandoutreachlongactingand
permanentFPserviceprovision)
1.2.Scaleupofmidwiferytraining.
1.3.ScaleupBasicEmergencyObstetricandNewbornCare
(BEmONC),ComprehensiveEmergencyObstetricandNewbornCare
(CEmONC
106

107. Cont’d
1.4.ConductmaternaldeathAuditing.
1.5.ServiceIntegrationwithemphasisonRH-HIVintegration,(in
particularFP-HIVpreventionlinkagesthroughcommonmessagesand
dualprotection)andharmonizedapproachamongallpartners.
1.6.Enhancethereferralsystemincludingpediatricreferral.
1.7.Routineimmunizationandwildpolioeradication
1.8.ExpandcommunityandfacilityIntegratedManagementofMother
NewbornandChildIllnesses(IMNCI).
107

108. Cont’d
1.9.EnhancedYouthFriendlyservices.
1.10.Capacitybuildingforprogrammanagementofmaternalandchild
healthservices.
1.11.Strengththehealthextensionprogram.
1.12.Developspecial,locallycontact-specificrelevantandeffective
maternalandchildhealthinterventionforpastoralistcommunities.
108

109. Cont’d
PoliciesandStrategies
▪ThegovernmentofEthiopiahasadoptednumerouslaws,policies
andprogramsthatadvancewomen'ssocialandreproductive
rights.
▪TheNationalHealthPolicy:Itsmainobjectiveis“togivea
comprehensiveandintegratedprimaryhealthcareina
decentralizedandequitablefashion”.
109

110. Cont’d
ThenationalhealthpolicyofEthiopiawasadoptedin1993basedonthe
principlesof
1)democratizationanddecentralization,
2)theprimaryhealthcareapproach,and
3)preventive,promotive,basiccurativeandrehabilitativeservices.
ThispolicyhasbeentheumbrellaforthedevelopmentofHealthSector
DevelopmentProgram(HSDP),otherhealthandhealthrelatedrelevant
policiesandstrategieshavealsobeendeveloped.
110

111. Cont’d
HealthDeliverySystem
▪Inthefiveyearperiod(2006–2010)(EthiopianFiscalYear(EFY)1998–
2002),thenumberofpublicsectorhealthfacilitiesrosedramatically.
▪Toensurethedeliveryofessentialhealthservicesthroughoutthe
country,thehealthcaresystemhasbeenreorganizedfromasixfirsttoa
fourandrecentlytoathreetieredsystem.
▪Theprimaryhospital,healthcenterandhealthpoststogetherforma
PrimaryHealthCareUnit(PHCU).Leveltwoisageneralhospitalto
serve1-1.5millionpeople;andlevelthreeisaSpecializedHospital
coveringapopulationof3.5-5millionpeople.
111

112. Cont’d
TheHealthSectorDevelopmentProgram(HSDP)
▪The20yearshealthsectorstrategyofEthiopiahas5yearrollingplan
knownastheHealthSectorDevelopmentProgram(HSDP)whichwas
startedbythefirstHSDP(1997/8-2001/02).
▪TheHSDPsarepartsofthecountry’spovertyreductionplan,whichis
calledPlanforAcceleratedandSustainableDevelopmentand
EradicationofPoverty(PASDEP)
112

113. Cont’d
▪RecordsfromtheexperienceofHSDPI-IIIshowedencouraging
improvementsbothinthehealthservicecoverageaswellasinthe
utilizationofservicesatalllevelsofthehealthcaresystemofthe
country.
113

114. Health Sector Transformation Plan (HSTP)
HSTP-I (July 2015–June 2020)
Reductions in maternal mortality (decreased 676 deaths per 100,000 live
births in 2011 to 401 in 2017).
under-5 mortality and infant mortality per 1000 live births decreased from
123 and 77 in 2005 to 59 and 47, respectively, in 2019.
However, over the years, there have been no significant reductions in
neonatal mortality (33 deaths per 1,000 live births in 2019).
114

115. Cont’d
HSTP-II (July 2020–June 2025)
HSTP-II has set ambitious targets to reduce the maternal mortality rate to
279 per 100,000 live births
Reduce under-5 and neonatal mortalities to 44 and 21 per 1,000 live births,
respectively
Increasing skilled delivery attendance to 76%
Coverage of ANC 4 to 81%,
115

116. cont’d
TheGovernmentofEthiopiadeveloped14strategicdirections,
alongwiththeirmajoractivities,toachievethetargetslaidoutin
HTSP-II
Enhanceprovisionofequitableandqualitycomprehensivehealth
service
Improvehealthemergencyanddisasterriskmanagement
Ensurecommunityengagementandownership
Improveaccesstopharmaceuticalsandmedicaldevicesandtheir
rationalandproperuse
116

117. Cont’d
✓Improveregulatorysystems
✓Improvehumanresourcedevelopmentandmanagement
✓Enhanceinformeddecision-makingandinnovations
✓Improvehealthfinancing
✓Strengthengovernanceandleadership
✓Improvehealthinfrastructure
117

118. Cont’d
Enhancedigitalhealthtechnology
Improvetraditionalmedicine
Enhancehealthinallpoliciesandstrategies
Enhanceprivateengagementintheheathsector
118

119. Cont’d
Five priority issues were identified as part of the transformation agenda
for HSTP-II:
Quality and Equity
Information revolution
Motivated, competent, and compassionate health workforce
Health financing
Leadership
119

120. Gender and Reproductive Health

121. Learning objectives:-
1.Identifytheconceptualdifferencesbetweensexandgender,and
developacommon understandingabouthowgenderis
constructed,maintained,andreinforced
2.Discussgenderrolesandrelations
3.Analyzegenderbasedinequalitiesanditsconsequences
4.DiscussgenderbasedviolencerelatedtoRH

122. The Concept of Gender
▪Genderreferstotheeconomic,socialandculturalattributesand
opportunitiesassociatedwithbeingmaleorfemaleina
particularsocialsettingataparticularpoint.
▪Itisthesocialconstructionofmaleandfemaleroles
▪Sexisthebiologicaldifferencebetweenmalesandfemales

124. Cont’d…
Genderstereotypes
▪Refertobeliefsthataresoingrainedinourconsciousnessthat
manyofusthinkgenderrolesarenaturalandwedonotquestion
them.
▪Typically,menareseenasbeingresponsibleforproductive
activitiesoutsidethehomeandwomenareresponsiblefor
productiveandreproductiveactivitieswithinthehome.
▪Genderrelationshavechangedovertime,becausetheyare
nurturedbyfactorsthatchangeovertime

125. Cont’d…
CharacteristicsofGender
✓Relational:-Women'sandmen'srolesandresponsibilitiesaresocially
determined(sociallyconstructed)
✓Hierarchical:-Powerrelations(unequalpowerrelationshipsduetothe
greaterimportanceandvaluetothecharacteristicsandactivitiesassociated
withwhatismasculine)
✓Changes:-Changesovertime(potentialformodificationthrough
developmentinterventions)
✓Contextspecific:-Varieswithethnicity,classcultureetc
✓Institutional:-Systemic(asocialsystemthatissupportedbyvalues,
legislation,religion,etc.)

126. Cont’d…
Thissexualdivisionoflaborislearnedandclearlyunderstoodby
allmembersofsociety.
Theserolesareclassifiedinthefollowingway;-
❖ProductiveRole:workdonebybothmenandwomen(but
primarilybymen),forpayincashorinkind,formarketingand
homeconsumption
❖ReproductiveRole:Childbearingandrearingresponsibilities
anddomestictasksdonebywomeninthehousetomaintainand
sustainthefamily

127. Cont’d…
❖CommunityManagingRole:voluntaryactivitiesundertaken
primarilybywomenatthecommunitylevel,asanextensionof
theirreproductiverole
❖Community PoliticsRole:Primarilyundertakenbymen,
involvingdecisionmaking
❖Intheareaofsexualityandsexualbehaviorwomenareexpected
tomakethemselvesattractivetomen,butbemorepassive,
guardingtheirvirginity,neverinitiatingsexualactivity,and
takingcaretoprotectthemselvesfromtheuncontrolledsexual
desiresofmen.

128. Cont’d…
“GenderBias”referstogenderbasedprejudice;assumptions
expressedwithoutareasonandaregenerallyunfavorable.
while”genderdiscrimination”referstoanydistinction,exclusion
orrestrictionmadeonthebasisofsociallyconstructedgender
rolesandnormswhichpreventsapersonfromenjoyingfullhuman
rights.

129. Cont’d…
GenderEqualityandEquity
Genderequalityreferstosimilartreatmentofwomenandmenin
lawsandpolicies,andequalaccesstoresourcesandservices
withinfamilies,communitiesandsocietyatlarge.
Genderequalityisbalancedrepresentationandparticipationof
womenandmenwithinpolicyandgovernanceandareallocation
ofpowerandredistributionofresourcesfrommentowomen.

130. Cont’d…
Genderequityontheotherhandreferstofairnessandjusticein
thedistributionofbenefitsandresponsibilitiesbetweenwomen
andmen.
Genderinequalitiesareunnecessary,avoidableandunjust.
Genderinequalityresultsunbalancedpatternsofhealthrisk,useof
healthservices,andhealthoutcomesbetweenwomenandmen.
Equitydoesnotmeananequaldistributionofresources,buta
differentialdistributionthatensureseachperson’sneedsaremet.

131. Cont’d….

132. Cont’d…
Genderbasedinequality(imbalance)anditsconsequences
▪Womenandmenhaveunequalaccesstoandcontrolover
resources;oftentoadisadvantageofwomen.
▪Havinggreateraccesstoandcontroloverresourcesusually
makesmenmorepowerfulthanwomeninanysocialgroup.
▪Thismaybethepowerofphysicalforce,ofknowledgeandskills,
ofwealthandincome,orthepowertomakedecisionsbecause
theyareinapositionofauthority.Menoftenhaveextendedtheir
decision-makingpowerovertoreproductionandsexualmatters
aswell.

133.  Th

ACCESSTOANDCONTROL
OVER
INTERNAL
RESOURC
ES
ECONOMIC
AND
SOCIAL
RESOURCES
POLITICAL
RESOURCE
S
INFORMATIO
N
/EDUCATION
TIME
POWER AND DECISION-
MAKING

134. Cont’d…
Genderinequitiesinhealthareconcentratedinthreetypesof
imbalance:-
✓Healthrisks,
✓Healthneedsand
✓Responsibilityinhealthcare
Consequencesofgenderinequalitycanbereflectedinvarious
areas.Higherrateofdropoutornon-enrolment,lowereducational
attainmentandskillsacquisition,povertyandpoorerhealthstatus
areexamples.

135. Areas of gender inequality in health
Opportunityto
enjoyhealth
Access to
health
Powerinhealth
sector
Healthrisk
Healthneeds
Responsibility
inthehealth
sector

136. Cont’d…
Theglobalgendergapindexexaminesthegapbetweenmen
andwomeninfourfundamentalcategories:-
❑Economicparticipationandopportunity
❑Educationalattainment
❑Politicalempowerment;and
❑Healthandsurvival.

137. Quiz (10%)
Define reproductive health?
Define reproductive health care?
Discuss criteria to select an indicator?
Explain gender discrimination and stereotype?
Discuss characteristics of Gender?
137

138. Maternal and child health
138

139. Safe Motherhood
What is safe motherhood?
Ensuring that all women receive the care they need to be safe and
healthy throughout pregnancy and childbirth.
Why safe motherhood?

140. Why Safe Motherhood?
Disparities
99% of the maternal deaths take place in developing countries
Greatest disparity between developed and less developed countries among
common basic health status indicators
Benefits of maternal health to perinatal and child health and survival
Maternal death is generally avoidable
(MATERNAL MORTALITY A “NEGLECTED TRAGEDY”)

141. Why Safe Motherhood
Safe Motherhood as a vital social and economic investment
When a woman is sick or dies
families lose her contribution to household management and provision of
care for children and other family members
the economy loses her productive contribution to the work force
communities lose a vital member whose unpaid labor is often central to
community life

142. Maternal Mortality
Maternal death:
The death of a woman while pregnant or
within 42 days after termination of pregnancy,
Irrespective of the site and duration of pregnancy,
from any cause related to or aggravated by the pregnancy or its
management,
but not from accidental or incidental causes.
142

143. Cont’d
Maternal morbidity:
Any deviation, subjective or objective, from a state of physiological or
psychological well being of women.
Women’s lifetime risk of Death:
the risk of an individual woman dying from pregnancy or childbirth during
her lifetime.143

144. Cont’d
MD is the TIP OF THE ICEBERG –For every maternal death 16 –50
mothers suffer from morbidity due to the consequences of pregnancy
and child birth.
ICD Late maternal death: the death of a woman from direct or
indirect obstetric causes more than 42 days but less than one year after
termination of pregnancy.
144

145. Cont’d
Globally
Every year, there are more than 210 million pregnancies, where
nearly
75 million are either unwanted or unplanned
Close to 600-9000/100,000maternal deaths each year (1 per min.)
1 maternal death=30 maternal morbidities
145

146. Africa
Each year in Africa, 30 million women become pregnant, and 18 million
give birth at home without skilled care
Every year over 250,000 African women die because of complications
related to pregnancy and childbirth.
Each day 700 women die of pregnancy-related causes.
12 of the 13 with the highest MMR in the world are in SSA countries
among which the top list includes Ethiopia
Pregnancy related complications, remains one of the major causes of
morbidity and mortality in SSA
146

147. Cont’d
Causes of maternal death:
Direct causes: are those that result from obstetric complications of the
pregnancy state from interventions, omissions, incorrect treatment or from
chain of events.
Examples: Abortion, Ectopic pregnancy, pre-eclampsia, Eclampsia,
Obstructed labor, infection, etc.
Seventy percentof maternal deaths are usually preventable.
A. Haemorrhage: Includes antepartum, postpartum, abortion, and ectopic
pregnancy.
147

148. Cont’d
B. Unsafe Abortion: It is claimed as the commonest cause of maternal death
in our country accounting for 20 –40% of deaths.
C. Hypertensive disorders of pregnancy: This includes pre-eclampsia,
eclampsia, etc.
Preeclampsia and eclampsia account for 10-12% of maternal deaths.
D. Obstructed Laborand uterine rupture: The prevalence of obstructed labor
is said to be 47 % in Ethiopia.
It accounts for 9% of the total maternal death.
148

149. Cont’d
E. Infection: introduction and multiplication of microbes in the pelvic
organs and other systems affecting the mother and new-born.
Includes infection of; uterus, tubes urinary systems, fetalinfections.
Accounts about 10% of MD.
149

150. Cont’d
Indirect causes of maternal death: deaths resulting from pre-existing
diseaseor disease that developed during pregnancy which are
aggravatedby the physiologic changes during pregnancy.
Includes: Anemia(the commonest), heart disease, DM, HIV/AIDS, TB,
Malnutrition
150

151. Maternal Mortality in Context: The Three D’s (Delays)
There are three phases during which delays can contribute to the death
of pregnant and postpartum women and their new-borns.
1.Delay in deciding to seek care
Failure to recognize signs of complications
Failure to perceive severity of illness
Cost consideration
Previous negative experience with the health system
Transportation
151

152. Cont’d
2. Delay in reaching care
Lengthy distance to a facility
Conditions of roads
Lack of available transportation
3. Delay in receiving appropriate care
Uncaring attitudes of providers
Shortages of supplies and basic equipment
Non-availability of health personnel
Poor skills of health providers
152

153. Cont’d
Life threatening delays can happen at home, on the way to care, or at the
place of care.
Therefore, plans and actions that can be implemented at each of these
points are mandatory.
Birth preparedness and complication readiness to reduce delays
Women-friendly care to enhance acceptability
153

154. Causes of Maternal Morbidity
Maternal morbidity is difficult to measure due to variation in the definition and
criteria to diagnose.
The risk factors for maternal morbidity include prolonged labor, haemorrhage,
infection, preeclampsia, etc.
the commonest long term complication of pregnancy and child birth include:
A. Infection: There is high risk of infection of the genital organs (cervix, uterus,
tubes, ovaries and peritoneum) after prolonged labor, when delivery takes place
in unclean settings, retained parts of conception after unsafe abortion and
delivery.
154

155. Cont’d
B. Fistula: holes in the birth canal that allow leakage from the urethra,
bladder or rectum into the vagina.
They present with continuous leakage of urine or fecesor both.
The commonest cause in our country is obstructed laboras opposed to
surgery and cancer in the developed world.
C. Incontinence: is leakage of urine upon straining or standing.
D. Infertility: Unable to be pregnant for a year despite unprotected
sexual intercourse.
155

156. Cont’d
E. Uterine prolapse: the falling or sliding of the uterus from its normal
position into the vaginal canal.
Commonest predisposing factors include prolonged labor, heavy
exercise, multiple childbirths, etc.
F. Nerve Damage: As a result of prolonged labor, there may be
compression or damage of the nerves in the pelvis (Sciatic nerve).
G. Psychosocial problems: maternal blues aggravated by other
conditions
H. Others, Include, pain during intercourse, anemia, etc.
156

157. Risk factors for Maternal Health
Socio-cultural factors: early marriage, early childbirth, harmful
traditional practices including female genital mutilation, etc.
Economy: Socio economic status affects the women’s status by affecting
their decision making roles in the community, educational status, health
coverage, level of sexual abuse, etc.
Inadequate Health Service Coverage: Most mothers do not get care
during pregnancy and most deliveries are unattended. This is due to lack
of transportation, distance from health facilities, small number of health
facilities, etc.
157

158. Cont’d
Psychological factors: For instance, after sexual abuse women are at
great risk of depression.
Health and nutrition services:The health status of women who are not
getting adequate amount of nutrients and proper reproductive health
services could be affected.
Interaction with providers: Some health care providers are,
unsympathetic and uncaring as they do not respect women's cultural
preferences. E.g. privacy, birth position, or treatment by women providers.
Gender Discrimination: E.g. lack of women empowerment, giving more
attention to a male child.
158

159. Measures of maternal mortality
There are three distinct measures of maternal mortality in widespread
use:
The maternal mortality ratio
The maternal mortality rate and
The lifetime risk of maternal death.
The most commonly used measure is the maternal mortality ratio
The maternal mortality rate, that is, the number of maternal deaths in a
given period per 1000 women of reproductive age during the same time
period, reflects the frequency with which women are exposed to risk
through fertility
159

160. Cont’d
The lifetime risk of maternal death takes into account both the
probability of becoming pregnant and the probability of dying as a result
of that pregnancy cumulated across a woman’s reproductive years.
In theory, the lifetime risk is a cohort measure, but it is usually calculated
with period measures for practical reasons.
It can be approximated by multiplying the maternal mortality rate by the
length of the reproductive period (around 35 years).
Thus, the lifetime risk is calculated as [1-(1-maternal mortality rate)
160

161. Cont’d
Why maternal mortality is difficult to measure?
Maternal mortality is difficult to measure for both conceptual and
practical reasons.
Maternal deaths are hard to identify precisely because this requires
information about deaths among women of reproductive age, pregnancy
status at or near the time of death, and the medical cause of death.
All three components can be difficult to measure accurately, particularly
in settings where deaths are not comprehensively reported through the
vital registration system and where there is no medical certification of
cause of death.
161

162. Cont’d
Why maternal mortality is difficult to measure?
Moreover, even where overall levels of maternal mortality are high,
maternal deaths are nonetheless relatively rare events and thus, prone to
measurement error.
As a result, all existing estimates of maternal mortality are subject to
greater or lesser degrees of uncertainty.
162

163. Cont’d
Why maternal mortality is difficult to measure?
Broadly speaking, countries fall into one of four categories:
Those with complete civil registration and good cause of death
attribution –though even here, misclassification of maternal deaths can
arise, for example, if the pregnancy status of the woman was not known
or recorded, or the cause of death was wrongly ascribed to a non-
maternal cause.
Those with relatively complete civil registration in terms of numbers of
births and deaths, but where cause of death is not adequately classified;
cause of death is routinely reported for only 78 countries or areas,
163

164. Cont’d
Why maternal mortality is difficult to measure?
Those with no reliable system of civil registration where maternal
deaths–like other vital events –go unrecorded.
Currently, this is the case for most countries with high levels of maternal
mortality.
Those with estimates of maternal mortality based on household
surveys, usually using the direct or indirect sisterhood methods.
These estimates are not only imprecise as a result of sample size
considerations, but they are also based on a reference point some time
in the past, at a minimum six years prior to the survey and in some cases
164

165. Cont’d
WHO, UNICEF and UNFPA have developed estimates of maternal
mortality primarily with the information needs of countries with no or
incomplete data on maternal mortality in mind, but also as a way of
adjusting for underreporting and misclassification in data for other
countries.
A dual strategy is used that adjusts existing country information to
account for problems of underreporting and misclassification and uses a
simple statistical model to generate estimates for countries without
reliable data.
165

166. Cont’d
Approaches for measuring maternal mortality
Commonly used approaches for obtaining data on levels of maternal
mortality vary considerably in terms of methodology, source of data and
precision of results.
As a general rule, maternal deaths are identified by medical certification in
the vital registration approach,but generally on the basis of the time of death
definition relative to pregnancy in household surveys (including sisterhood
surveys), censuses and in Reproductive Age Mortality Studies (RAMOS).
166

167. Cont’d
Approaches for measuring maternal mortality
Vital registration
In developed countries, information about maternal mortality is derived
from the system of vital registration of deaths by cause.
Even where coverage is complete and all deaths medically certified, in
the absence of active case-finding, maternal deaths are frequently
missed or misclassified.
In many countries, periodic confidential enquiries or surveillance are
used to assess the extent of misclassification and underreporting.
167

168. Cont’d
Approaches for measuring maternal mortality
Vital registration
A review of the evidence shows that registered maternal deaths should
be adjusted upward by a factor of 50% on average.
Few developing countries have a vital registration system of sufficient
coverage and quality to enable it to serve as the basis for the assessment
of levels and trends in cause-specific mortality including maternal
mortality.
168

169. Cont’d
Approaches for measuring maternal mortality
Direct household survey methods
Where vital registration data are not appropriate for the assessment of cause-
specific mortality, the use of household surveys provides an alternative.
However, household surveys using direct estimation are expensive and
complexto implement since large sample sizes are needed to provide a
statistically reliable estimate.
The most frequently quoted illustration of this problem is the household survey
in Addis Ababa, Ethiopia, where it was necessary to interview more than 32,300
households to identify 45 deaths and produce an estimated MMR of 480.
169

170. Cont’d
Approaches for measuring maternal mortality
Indirect sisterhood method
The sisterhood method is a survey-based measurement technique that in
high-fertility populations substantiallyreduces sample size
requirements since it obtains information by interviewing respondents
about the survival of all their adult sisters.
Although sample size requirements may be reduced, the problem of
wide confidence intervals remains.
170

171. Cont’d
Furthermore, the method provides a retrospective rather than a current
estimate, averaging experience over a lengthy time period (some 35 years,
with a midpoint around 12 years before the survey).
For methodological reasons, the indirect method is not appropriate for use
in settings where fertility levels are low [total fertility rate (TFR)
171

172. Cont’d
Approaches for measuring maternal mortality
Direct sisterhood method
The Demographic and Health Surveys (DHS) use a variant of the sisterhood approach, the
“direct” sisterhood method.
This relies on fewer assumptions than the original method, but it requires larger sample sizes
and the information generated is considerably more complex to collect and to analyze.
The direct method does not provide a current estimate of maternal mortality, but the greater
specificity of the information permits the calculation of a ratio for a more recent period of time.
Results are typically calculated for a reference period of seven years before the survey,
approximating a point estimate some three to four years before the survey.
172

173. Cont’d
Because of relatively wide confidence intervals, the direct sisterhood
method cannot be used to monitor short-term changes in maternal mortality
or to assess the impact of safe motherhood programmes.
The Demographic and Health Surveys have published an in-depth review of
the results of the DHS sisterhood studies (direct and indirect methods) and
have advised against the duplication of surveys at short time-intervals.
WHO and UNICEF have issued guidance notes to potential users of
sisterhood methodologies, describing the circumstances in which it is or is
not appropriate to use the methods and explaining how to interpret the
results.173

174. Cont’d
Approaches for measuring maternal mortality
Reproductive Age Mortality Studies
The Reproductive Age Mortality Study –RAMOS –involves identifying and
investigating the causes of all deaths of women of reproductive age.
This method has been successfully applied in countries with good vital
registration systems to calculate the extent of misclassification and in
countries without vital registration of deaths.
Successful studies in countries lacking complete vital registration use multiple
and varied sources of information to identify deaths of women of reproductive
age; no single source identifies all the deaths. 174

175. Cont’d
Subsequently, interviews with household members and health-care providers and
reviews of facility records are used to classify the deaths as maternal or otherwise.
Properly conducted, the RAMOS approach is considered to provide the most
complete estimation of maternal mortality, but can be complex and time consuming
to undertake, particularly on a large scale.
Verbal autopsy
Where medical certification of cause of death is not available, some studies assign
cause of death using verbal autopsy techniques.
However, the reliability and validity of verbal autopsy for assessing cause of death in
general and identifying maternal deaths in particular, has not been established
175

176. Cont’d
Census
There is growing interest in the use of decennial censuses for the
generation of data on maternal mortality.
A high-quality decennial census could include questions on deaths in
the household in a defined reference period (often one or two years),
followed by more detailed questions that would permit the
identification of maternal deaths on the basis of time of death relative
to pregnancy (verbal autopsy).
176

177. Summary of Causes of maternal death
177

178. Neonatal health
178

179. When are child deaths occurring?
The 10.6 million annual child deaths are not distributed
evenly over the 0-4 year age period
More than 70% of all child deaths occur in the first year of
life

180. Neonatal health
Two-thirds of neonatal deaths occur within the first
week
• Two-thirds of neonatal deaths in the first week occur
within 24 hours of life
• Major causes of neonatal deaths globally are: birth
asphyxia (23%), infections (36%), and preterm
complications (27%)
• Neonatal death contributes to 40% of under 5yr
mortality globally

181. Neonatal health
Preterm and LBW babies are at higher risk of complications and
death
Preterm babies are babies born before 37 weeks gestation, LBW
(low birth weight) babies born with a birth weight of fewer than
2500 grams
Low birth weight is associated with 60-80% of neonatal deaths

182. Neonatal health
Infections: in very high mortality settings almost 50% of
deaths are due to severe infections including neonatal
sepsis, pneumonia, diarrhea, and neonatal tetanus

183. Neonatal health
Birth Asphyxia: When a baby doesn’t begin or sustain adequate
breathing at birth
5-10% of all newborns need resuscitation at birth
Nearly 1 million babies die each year because they don’t breathe
normally at birth

184. Progress has been variable
Neonatalmortalityhasfallenatalowerratethanpost-neonatalorearly
childmortality
Relativelygreaterprogresshasbeenmadeinsomeregionsand
countries
e.g.neonatalmortalityisnow58%lowerinhigh-incomecountriesthanin1983,
comparedtoa14%reductioninlow/middle-incomecountries
Largevariationsinmortalityratesexistevenwithinthesamecountry

185. Neonatal health
When do we need to worry?
➢Inadequate shelter,
➢low temperature
➢Low exclusive breastfeeding practice
➢No or limited access to neonatal health care
➢No or limited attendance of deliveries by a skilled
attendant
➢No or limited care in the first 24-48hrs after delivery
➢High neonatal tetanus rate and/or low TT coverage
among women of reproductive age

186. Neonatal health
How do we plan a Prevention/response program
Link neonatal health response with primary health care and
reproductive health care response plan.

187. Neonatal health
Intheacuteinitialphase:
EnsureessentialneonatalcareisincorporatedintheMinimum
InitialServicePackageforreproductivehealth
Ensurethatneonatalillnessanddeathareincludedin
surveillanceformatatthecommunityandfacilitylevel
Promoteimmediateandexclusivebreastfeeding,discourage
introductionorpromotionofartificialfeeding
Distributebabycloth(hatandwarmclothing)incontextswhereit
isneeded(coldtemperature)
Includeneonatalresuscitationkitinmedicalkitsupplies

188. Neonatal health
Aftertheacuteinitialphase:
Dependingonprogramdirection,childhealthorreproductive
healthincludealltheessentialcomponentsofneonatalhealthcare
addressingthethreemaincausesofmortality
Includeneonatalillnessanddeathdatainpopulation-based
surveys,monthlyreportingformats

189. Neonatal health
Howdoweworkwiththecommunity?
Promoteimmediateandexclusivebreastfeeding
Ifneededorganize‘privatebreastfeedingcornersorrooms’
Promotekangaroomothercare(KMC)–forthecareofnpreterm/LBW
babies
Promotecleandeliverypracticeandattendanceofbirthsby skilled
attendants
Awarenesswherethecommunitycanaccessneonatal,andmaternalhealth
care
•Traincommunityhealthworkersandvolunteersonnewborncare,andcare
inthefirstdaysoflife

190. Adolescent and youth reproductive health
190

191. Definition
World Health Organization defines adolescents as individuals between 10
and 19 years of age.
The broader terms "youth" and “young” encompass the 15 to 24 year-old
and 10 to 24 year-old age groups, respectively.
191

192. Cont’d
Definitions:
Period between childhood & adulthood
Involves distinct physiological, psychological, cognitive, social &
economic changes.
1.Adolescent: 10-19 years of age
2.Youth: 15-24 years of age
3.Young people: 15-29 years of age

193. Cont’d
For girls, puberty is a process generally marked by the production of
estrogen, the growth of breasts, the appearance of pubic hair, the growth
of external genitals, and the start of menstruation.
For boys, it is marked by the production of testosterone, the enlargement
of the testes and penis, a deepening of the voice, and a growth spurt.
193

194. Why focus on adolescent and young people?
I. Number/ proportion:
Account to 60% of the population in Ethiopia (below 25 years of age)
II. Nature of adolescents and young on sexuality
Major physical, cognitive, emotional, sexual and social changes occur
during adolescence and affects young people’s sexual behavior

195. Nature of adolescents and young on sexuality…
Many young people engaged in risky behaviors due to
Curiosity
Peer pressure
Sexual maturation
A feeling of vulnerability
A sense of omnipotence
The increasing gap between puberty and marriage: Unmarried youth
require reproductive health care for a longer period

196. Why focus…?
III. Health and health related issues:
Higher proportion of HIV and STI among adolescents and young
Higher risk of maternal death between 15-19 year of age as compared to 25-29
years of age (4X)
Many young women are sexually active and do not use contraceptive methods
1.Do not expect to have sex &
2.lack knowledge about contraceptive
Adolescent births are more likely to result in LBW, premature birth, stillbirth &
Neonatal deaths.

197. Youth and diversity
–Different backgrounds
–Different stages of life
–Different individual needs

198. Barriers for young women
•Gender roles and stigma around youth sexuality
•Gender-based violence
•Child marriage
•Poor knowledge of abortion laws, services and technology
•Lack of youth-focused services
•Health providers attitudes

199. Adolescents today
The current generation of young people is the healthiest, most educated,
and most urbanized in history.
However, there still remain some serious concerns:
Education:
Sexuality
Health
199

200. Characteristics of the adolescence period
The period when the individual progresses from the point of initial
appearance of secondary sex characteristics to sexual maturity.
It is period when psychological processes and patterns of identification to
those of an adult.
Transition from the state of total socio-economic dependence to relative
independence.
200

201. Cont’d
Period of rapid physiological changes and vulnerability to physical,
psychological and environmental influences.
Period of physical, biological, psychological and social maturity from
childhood to adulthood.
201

202. Effects of social environment on adolescent RH behavior
Factors Positive influences Negative influences
Education Good health and sex education followed
by correct behavior
Early unwanted pregnancy, school
dropping, unemployment, prostitution,
drug abuse, crime, etc,
Media Spread information on healthy sexuality Pornography, smoking, crime (films,
papers, advertisement)
Entertainment Sports, in door games, educational filmsCrimes, drugs and alcohol abuse,
prostitution, early sexual activities
Family Integrated stable families are role models.
They can give appropriate information and
guidance on healthy life style
Abusive behaviour in families
Disintegrated families
Residence Healthy neighborhood "negative neighborhood" e.g.
prostitution areas
Health services Accessible information and services for
adolescents
Negative attitudes of health
professionals on adolescent sexuality
Religion Spiritual support Facilitation of the
adolescents in different activities
Prohibition of information on sexuality
202

203. Reproductive Health Risks and consequences for adolescents
Adolescent reproductive health is affected by:
pregnancy
Abortion
STIs
sexual violence
the systems that limit access to information and clinical services
Nutrition
psychological well-being
Economic and gender inequities that can make it difficult to avoid forced,
coerced, or commercial sex. 203

204. Pregnancy
In many parts of the world, women marry and begin childbearing during
their adolescent years.
Pregnancy and childbirth carry greater risk of morbidity and mortality
for adolescents than for women in their 20s, especially where medical
care is scarce
Girls younger than age 18 face two to five times the risk of maternal
mortalityas women aged 18-25 due to prolonged and obstructed labor,
hemorrhage, and other factors
204

205. Cont’d
Potentially life-threatening pregnancy-related illnesses such as
hypertension and anemiaare more common among adolescent mothers,
especially where malnutrition is endemic.
One in every 10 births worldwide and 1 in 6 births in developing
countries is to women aged 15-19 years.
205

206. Cont’d
Unsafe abortion: About one in 10 abortions worldwide occurs among
women age 15-19
Each year one million to 4.4 million adolescents in developing countries
undergo abortion
Most of these procedures are performed under unsafe conditions due to:
Lack of access to safe services.
Self-induced methods
Unskilled or non-medical providers
Delay in seeking procedure
206

207. Abortion and Youth in Ethiopia
Many young people are sexually active (age at first sexual
intercourse for women 16.6 years in 2016 )
•Contraception use among youth is very low
•54% of pregnancies to girls under age 15 and 37% to ages 20-24 are
unwanted (MOH 2007:11 NAYRHS 2007-15)
•In 2008, 101 unintended pregnancies occurred per 1,000 women
aged 15–44 and 42% of all pregnancies were unintended (Singh et al
2010)

208. Cont’d
STIs, including HIV/AIDS: The highest rates of infection for STIs,
including HIV, are found among young people aged 20 to 24; the next
highest rate occurs among adolescents aged 15 to 19
Sexually transmitted infections can lead to life-long health problems,
including infertility.
Worldwide, half of all sexually transmitted infections occur in
adolescents. 208

209. Cont’d
Female Genital Cutting (FGC): FGC, the partial or complete removal of
external genitalia or other injuries to the female genitalia, is a deeply
rooted traditional practice that has severe reproductive health
consequences for girls.
In addition to the psychological trauma at the time of the cutting, FGC
can lead to infection, hemorrhage, and shock. Uncontrolled bleeding or
infection can lead to death
209

210. Cont’d
Commercial Sex: Sexual exposure is occurring at ages as young as 9-12
years as older men seek young girls as sexual partners to protect
themselves from STD/HIV infection.
In some cultures, young men are expected to have their first sexual
encounter with a prostitute.
Adolescents, especially young girls, often experience forced sexual
intercourse in sub–Saharan Africa, some girls’ first sexual experience is
with a sugar daddy, who provides clothing, school fees, and books in
exchange for sex. 210

211. Cont’d
Sexual violence: Rape and involuntary prostitution can result in physical
trauma, unintended pregnancy, STIs, psychological trauma and increased
likelihood of high risk sexual behavior
211

212. RH indicators on adolescent and youth in Ethiopia
EDHS 2000, 2005, 2011 & 2016

213. Trends in use of contraception
7
5
2 2
14
13
3
9
29
27
2
22
33.9
33.4
2
22.8
0
5
10
15
20
25
30
35
40
Any Method Any Modern Method Pill Injectables
Percent of sexually experienced women age 15-24 who are using
contraception
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS
213

214. Trends in family planning knowledge
82
87
90
95
97
9998.1 97.9
0
20
40
60
80
100
120
Women Men
Percentage who know about modern contraception, among women and
men aged 15-24, who had sex in the last 30 days
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS
214

215. Trends on family planning knowledge
39
57
58
51.08
0
10
20
30
40
50
60
70
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHSA
Percent of women age 15-24 who heard
or saw a FP message on radio, TV, in
print medias or community events
40
51
65
43
0
10
20
30
40
50
60
70
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS
Percent of men age 15-24 who heard or
saw a FP message on radio, TV, in print
medias or community events
215

216. Trends in unmet need for family planning
216
31
28
23
14.6
7
9
2
2.5
0
5
10
15
20
25
30
35
40
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS
Percent of currently married women aged 15-24 with unmet need for FP
SpacingLimiting

218. Trends of age specific fertility rate
0
50
100
150
200
250
300
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Births per 1000 women
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS
218

220. Reasons youth fail to receive RH care service
Poor treatment
Fear of being judged by service provider
Lack of privacy and confidentiality
Feeling that services are intended for married people
Unaware of service locations or services offered
Service fee (no/low pocket money at hand)

221. Youth Friendly Health services
Definition: WHO describes as
“Services that are :
Accessible
Safe
Effective
Acceptable and
Appropriate for adolescents in meeting their need, in the right
place, and at the right price (free where necessary)”

222. Approaches for working with youth directly
1.Motivation-Stimulatingbehaviorchangesinindividualsbymarketing
aproduct,serviceoraction
2.HealthEducationinreproductivehealthissues
3.Counseling
4.RHservices-SuchasSTIscreening&treatment,FP,pregnancycare…

223. Characteristics of youth friendly service
Programmatic characteristics
Youth are involved in program design
Both boys & girls are welcomed and served.
Unmarried clients are welcomed & served
Group discussions are available
Parental involvement is encouraged but not required
Affordable fees are available
Drop-in clients are welcomed

224. Services intended to be provided as a package in YFS
1.Information and Counseling on SRH issues, and sexuality.
2.Promotion of healthy sexual behaviors through various methods including peer
education
3.FP information, counseling and methods including emergency contraceptive
methods
4.Testing Services: Pregnancy, HCT.
5.Prevention and Management of STIs
6.ANC, Delivery Services, PNC and PMTCT
7.Abortion and Post Abortion Care
8.Appropriate referral linkage between facilities at different levels

225. Service provider characteristics
Staff are trained about adolescent issues
Respect is shown to young people
Privacy & confidentiality maintained
Adequate time is given for client-provider interaction
Peer counselors are available

226. Health facility characteristics
Convenient hours
Convenient location
Adequate space
Sufficient privacy
Comfortable surroundings

227. HIV/AIDS and PMTCT
227

228. Definition of terms
➢What is HIV?
➢What is AIDS ?
➢What is PMTCT ?
2/21/2023228

229. Definition
➢HIVstandsforHumanImmunodeficiencyViruswhichprimarilyattacks
theimmunesystem.
➢HIVisfromaspecialfamilyofvirusesknownasretroviruses.
➢AIDSstandsforAcquiredImmuneDeficiencySyndrome.
➢PatientswhoareinfectedwithHIVwilldevelopsignsandsymptomsas
aresultofimmunedepressionwhichiscollectivelycalledAIDS.
➢PMTCTstandsforpreventionofmother-to-childtransmission
2/21/2023229

230. HIV/AIDS Epidemiology
➢AccordingtoUNAIDS2020report,bytheendof2019,75.7million
peoplegloballywereinfectedwithHIVsincethestartofthe
pandemicin1981,
➢Withnearly33milliontotaldeaths.
➢Therewere38.0millionpeoplelivingwithHIVin2019and1.7
millionpeoplebecamenewlyinfectedinthesameyear.
➢TheglobalcumulativeincreaseinpeoplelivingwithHIV(PLHIV)
ismainlyduetoimprovedaccesstoART(increasedsurvival),
alongsidedecliningnewHIVinfections(thoughitisstillvery
high).
2/21/2023230

231. HIV/AIDS Epidemiology cont.….
➢Despiteglobaleffortstoeliminatemother-to-childtransmissionof
HIV,15%ofpregnantwomenlivingwithHIVdidnothaveaccessto
antiretroviraldrugstopreventtransmissionofHIVtotheirchildren
in2019.
➢UnlessthesepregnantwomenareputonARTandviralsuppression
(<50copies/mlafter3-6monthsonART)isachieved,thechanceof
MTCTwillbehigh.
➢Thereare1.8millionchildren0-14yearslivingwithHIVin2019.
2/21/2023231

232. HIV/AIDS Epidemiology cont.….
➢Thenationaladult(15-49years)prevalenceofHIVin2019in
Ethiopiawas0.9%,withthehighestprevalencebeinginfemales
(1.2%).
➢EstimatednumberofPLHIVis670,000;44,000arechildrenlessthan
15yearsofage.
➢Currently,thereisamixedtypeofdistributionwithwideregional
variationsandhighconcentrationinurbanhotspotareas.
2/21/2023232

233. HIV/AIDS Epidemiology cont.….
➢ThereareseveralsubpopulationswithHIVprevalenceexceeding
5%inurbanareas.
➢Differenceshavebeenalsoobservedintheprevalenceamong
regionsandcityadministrations.
➢GambellahasthehighestadultHIVprevalence(4.32%)followedby
AddisAbaba(3.58%),whileSomali(0.16%)andSNNP(0.42%)
regionshavethelowestprevalence.
2/21/2023233

234. HIV/AIDS Epidemiology cont.….
➢Accordingtonationalestimates,HIVprevalencehasdeclined
from7.9%in2004to2.9%in2018inurbanareasofEthiopia.
➢However,thedataonruralareas,hasshownnosignificantdecline
butratherstabilized.
➢Forinstance,theprevalenceinruralareaswas1%in2004and
stabilizedat0.4%from2012to2018.
➢AccordingtoEDHS2016,thecurrentHIVprevalenceisseven
timeshigherinurbanareasthaninruralareas(2.9%versus0.4%,
respectively).
2/21/2023234

235. HIV/AIDS Epidemiology cont.….
➢AlthoughtheprevalenceofHIVamongthepregnantpopulationshoweda
decliningtrend,paralleltothatofthegeneralpopulation,theprevalence
wasstillhigheramongstpregnantwomen.
➢AccordingtoUNAIDSdatain2019estimation,5.4%ofpregnantwomen
wereHIVpositive.
➢Nationally,in2019,therewereatotalof19,110HIV-positivepregnant
women.
➢Ofwhich,only14,149(74%)womenwereaccessingPMTCTinterventions,
➢whichisfarbelowtheglobalachievementofmorethan85%.
2/21/2023235

236. Modes of HIV transmission:
➢Unprotectedsexualpractice(anal,vaginal,oral)withaninfected
person
➢Transfusionwithinfectedbloodorbloodproducts
➢Theuseofneedles,syringes,andcuttingorperforatingobjects
contaminatedbyHIV-infectedblood.
➢Sharingcontaminatedsharpforcertaintraditionalpractices;tooth
extraction,uvulectomy,femalegenitalmutilation,circumcision,and
tattooing.
➢MTCTduringpregnancy,laboranddelivery,andbreastfeeding
frominfectedwomen
➢Organtransplantfromaninfecteddonor
2/21/2023236

237. MTCT
MTCTcanoccurduringpregnancy,childbirth,orthrough
breastfeeding
Asamodeoftransmission,MTCTaccountsformorethan10%ofall
newHIVinfectionsglobally.
Over90%ofnewinfectionsininfantsandyoungchildrenoccur
throughMTCT
Intheabsenceofinterventions,theriskofMTCTis20-45%,withthe
highestratesinpopulationswithprolongedbreastfeeding
2/21/2023237

238. MTCT Cont.….
▪TheriskofMTCTcanbereducedtolessthan2%withapackageof
evidence-basedinterventions
▪PMTCTminimizestheverticaltransmissionofHIVduring
pregnancy,labor,andbreastfeeding.
▪PMTCTsaved1.4millionHIV-exposedchildrenfromHIVinfection
b/n2010to2018(UNAIDS,2019)
2/21/2023238

239. MTCT Cont.….
▪HIV/AIDSprevalencedecreasedby25%againfrom2010to2018
years
▪SDG2015to2030plannedongoal3.3tojusteliminateAIDS
epidemicsin2030
2/21/2023239

240. TIMINGOFMOTHER-TO-CHILDTRANSMISSION OFHIV
2/21/2023240
During labor and delivery (10-
20%)
During
breastfeeding
(5-20%)

241. Risk factors for MTCT OF HIV
A. Viral factors
Viral load
Viral resistance
B. Maternal
Maternal immunological status
Maternal nutritional status
Maternal clinical status
Behavioral factors
Antiretroviral treatment
2/21/2023241

242. Risk factors for MTCT OF HIV Cont.…
C. Obstetrical
Prolonged rupture of membrane
Mode of delivery
Intrapartum hemorrhage
Obstetrical procedures
Invasive fetal monitoring
D. Fetal and neonatal
Prematurity
Multiple pregnancies
Breastfeeding
Gastrointestinal tract
factors
Immature immune system
2/21/2023242

243. 2/21/2023243

244. 1.Primaryprevention
Communicationforbehaviorchange(ABCHIVinfectionapproach)toprotect
reproductive-agemenandwomenfrombecominginfectedwithHIVand
otherSTIs
ProvidevoluntarycounselingandtestingservicesfollowingtheNationalHIV
CounselingandTestingGuidelines
Promotecorrectandconsistentuseofcondoms
Encourageopendiscussiononreproductivehealthissuesbetweenparents
andtheirchildren
EarlydiagnosisandtreatmentofSTIs
2/21/2023244

245. 2. Prevention of unintended pregnancy Among HIV positive women
Provide family planning counseling and service integrated into all
potential PMTCT and VCT service sites
Provide health education about the use of dual family planning
service
Ask and counsel women about any drug they are using
2/21/2023245

246. 3. Prevention of HIV transmission from infected women to their infants
Ensureavailabilityofantiretroviraldrugsandotherappropriatesuppliesfor
PMTCT
ProvidetestingandcounselingservicesintegratedwithANC,labor&
delivery,andpostnatalcareusinganopt-outapproach.
Saferobstetricalpractices
Provideappropriatecounselingoninfantfeedingandsupportexclusive
breastfeeding
2/21/2023246

247. 4.Treatment,care,andsupportforHIV-infectedwomen,
theirinfantsandfamily
ProvideARTforallpregnantwomen
Ensureappropriatefollow-upofinfantsborntoHIV-positivewomen
includingOIprophylaxisandearlyinfantdiagnosis(DBS)at6weeksofage.
ProvideHIVtestingforfamily
LinkPMTCTwithcareandsupportinitiativesorganizedforinfantsandHIV-
infectedwomen
2/21/2023247

248. Care and treatment for HIV Positive pregnant, Laboring, and
lactating women
✓TestingandCounselingusinganopt-outapproach
✓WHO Clinical Staging
✓Screening for Opportunistic infections(OIs)
✓Management of OIs
✓Initiating ART at ANC
✓Adherence Preparation, Monitoring, and Support
✓Nutritional and social support
2/21/2023248

249. Testing and Counseling
➢AllwomenwithunknownHIVstatuscomingforMCHservices
shouldhavetheirHIVstatusdetermined
➢Encouragepregnant/lactatingwomentoattendHCFwiththeir
partnersandensurethatchildrenofHIV-positivemothersaretested
➢Remindpregnantwomenduringpre-testsessions(individualor
group)thattheycandeclineHIVtestingwithoutanysubsequent
consequence
2/21/2023249

250. TestingandCounselingConti…
ResultofHIVtestingshouldalwaysbeofferedinaconfidential
setting
Effectivepost-testcounselingofpatientstestingpositiveisessential
toassuretheirparticipationinfullPMTCTservices
2/21/2023250

251. Testing and Counseling Cont…
❑Prioritizeimmediateinformationtobedelivered
Informationonapositiveresult,medicalhelpavailable,disclosure,
andriskreductioncanbeprovidedonthefirstdayandothers
gradually
Thereforewhatcounselingisimmediatelyrequiredisbasedonthe
gestationalageorstageoflabortheneedandthelevelof
understandingofyourclient
2/21/2023251

252. WHO Clinical Staging
HIV-associated conditions are grouped into 4 WHO clinical stages that correlate with disease
progression and the likelihood of survival
Stage 1: Asymptomatic
Stage 2: Mild
Stage 3: Moderate
Stage 4: Severe
•It should be part of the baseline assessment (first visit) on entry into a care and treatment program
•Used to guide decisions on when to start co-trimoxazole prophylaxis and monitoring patient
response (if CD4 is not available)
•Following initiation of ART, staging on therapy (T-staging), using the same clinical parameters,
should be performed regularly as a means of monitoring ARV treatment success or failure.
2/21/2023252

253. Screening for Opportunistic infections OIs
❖BeforeinitiatingARTandateverysubsequentvisitprovidermust
screenforpossibleopportunisticinfectionthrough:
✓Aproperfocusedhistorybyaskingactivelyforsymptoms
✓Astandardphysicalexam
✓Useoflaboratorytests
2/21/2023253

254. Care and treatment……
➢Giving preventive service that includes:
▪Early intervention to prevent OIs and other HIV-related risk behavior
▪Co-trimoxazolepreventive therapy for both mother and infant
▪INH preventive therapy for preventing Tuberculosis
▪ITN to prevent malaria
2/21/2023254

255. Cotrimoxazole Preventive Therapy (CPT)
❑Give CPT to mother :
✓AnyWHOclinicalstageandCD4<350cellspermm3OR
✓WHOclinicalstage3or4irrespectiveofCD4level
✓AndifCD4countisnotavailablegiveCPTatWHOclinicalstages2,3and
4
2/21/2023255

256. Introduction to ARVs
What is ART?
ART stands for Anti-Retroviral Therapy; the treatment of HIV-infected
individuals with antiretroviral drugs.
What is HAART?
H-Highly, A-Active, A-anti, R-retroviral, T-Therapy
It is the use of three or more antiretroviral drugs for the treatment of HIV
infection.
2/21/2023256

257. The goal of ART
Tosuppressthereplicationandreducethenumberofvirusesintheblood
IncreasethenumberofCD4asmuchaspossibleandfinallyimprovethe
generalhealthoftheclient.
Antiretroviraltherapysuppressestheviralreplicationtoabelowdetectable
level,
Howevertheviruscanneverbeeradicatedcompletelyfromthebody;
hencethepersonshouldtakethedrugslifelong,evenifthesymptomshave
disappeared.
Sincetheviruscannotbeeradicated,safersexusingacondomshouldbe
practiced.
2/21/2023257

258. ARV Drugs for Pregnant Women
TherearefourmajorclassesofARVdrugsavailableforusein
Ethiopia:
1.TheNRTI:Thisstandsfor'NucleosideandNucleotideReverse
TranscriptaseInhibitors'
2.TheNNRTI:Thisstandsfor'Non-NucleosideReverse
TranscriptaseInhibitors.
3.INSTIs:IntegrasestrandtransferInhibitors
4.ThePI:ThisstandsforProteaseInhibitor.
2/21/2023258

259. Site of actions for NRTI, NNRTI, and PI
2/21/2023259

260. Advantages of Combination therapy.
➢Ittakesthreedrugstohavesustainedviralsuppression(lowlevelof
virusinthebody).
➢Antiretroviraldrugsfromdifferentdruggroupsattackthevirusin
differentways.
➢Combinationsofanti-HIVdrugsmayovercomeordelayresistance.
2/21/2023260

261. ART for pregnant women
➢ARTwillimprovethehealthofthewomanandisthemosteffectiveintervention
indecreasingtheriskoftransmissionofHIVtotheinfant.
➢HIV-positivestatusistheonlyrequirementforstartingpregnantorlactating
womenonART
➢AllHIV-positivepregnantwomenshouldbestartedonARTassoonaspossible
irrespectiveofgestationalage,clinicalstage,andCD4count.
➢HAARTforHIV-positivepregnantisindicatedbasedontheWHOprogrammatic
updateissuedinApril2012,OptionB+(test-and-treatprinciple).
➢Oncestarted,awomanshouldcontinuetakingARTforherentirelife.
2/21/2023261

262. CONT…
▪Sincetreatmentisanticipatedtobelifelong,makesureyourclientunderstandsthe
importanceofadherence.
▪Pregnantandpost-partumwomenneedadherencesupport—makeuseofMother
SupportGroup
▪ARVssideeffects,drug-druginteraction,andneedforadherenceshoulddiscuss
beforeinitiation
2/21/2023262

263. CONT….
oIfpregnantorlactating,awomanshouldstartARTwithin7days
oAlaboringmothershouldbeinitiatedonARTimmediately,accompaniedby
strongadherencecounselingandclosefollowup
2/21/2023263

264. Option B+
✓Requiresjustonepilltakenoncedaily
✓NoneedforCD4testtoinitiateART
✓Makesbreastfeedingsafer
✓Mothersstarttreatmentearly,sothequalityoflifeandsurvival
arebetter
2/21/2023264

265. Benefits of Option B+
✓Requiresjustonepilltakenoncedaily
✓NoneedforCD4testtoinitiateART
✓Makesbreastfeedingsafer
✓Mothersstarttreatmentearly,sothequalityoflifeandsurvivalarebetter
2/21/2023265

266. Benefits of Option B+ CONT…
✓Maintainscontinuityofcare:ANCtopost-weaningsoimprovesinfanttesting
aswellaspost-partumuptakeofFPservices
✓MinimizeHIVtransmissionamongadiscordantpartnership
✓Ongoingtreatmentofthemotherwillprotectfuturepregnanciesfromthestart
ofconception.
2/21/2023266

267. Challenges of Benefits of Option B+
✓Treatmentisintendedtobelifelong
✓Adherenceisalsoveryimportanttopreventtheoccurrenceoftreatment
failure
✓Pooradherencemaycausetreatmentfailure
✓Sideeffectsofdrugsneedtobemonitored
2/21/2023267

268. Recommended Option B+ ARV drugs regimen in PMTCT
Scenario:-DiagnosisofHIVandinitiationof
ARTat:
Typeofregimenforthe
woman
ANC(newlyidentified) TDF+3TC+DTG
Intra-partum(L&D),newlyidentified TDF+3TC+DTG
Postpartumperiod(newlyidentified) TDF+3TC+DTG
PregnantmotheronPre-ARTfollowup TDF+3TC+DTG
AlreadyonHAARTbeforepregnancy Continuewiththeregimen
thewomanhasstarted
2/21/2023268

269. Summary of sequencing for preferred first, second and third-
line Option B+ ART regimens in pregnant women
Population Preferred First
line
Regimens (PFR)
Alternative First
line
Regimens (AFR)
Special
circumstanc
es
c
(SC)
Women & adolescent
girls who have desire
for pregnancy or are
pregnant (including
those with TB/HIV
coinfection)
b
TDF + 3TC + DTG
(FDC)
TDF + 3TC +
EFV*
AZT + 3TC +
EFV*
AZT + 3TC + DTG
TDF+3TC+
ATV/r
**
AZT+3TC +
ATV/r
**
2/21/2023269

270. Adherence advice
ProvidingbasicinformationonHIVanditsmanifestations
Clearlystatingbenefitsandsideeffectsofdrugs
Identifyingwhenaclientshouldseekurgenthelp
Explaininghowmedicationsshouldbetaken
Stressingtheimportanceofnotmissinganydoses
2/21/2023270

271. Monitoring of women initiated on option B+
oAll HIV-infected individuals require a standard clinical assessment at
every visit
oAteachvisitHCWshouldbecheckedfor:
✓HIV-relateddiseasesincludingTBscreeningquestions
✓ChangeinWHOstage;anyfindingsuggestingARTTxFailure
✓Drugsideeffects(ARV,CTX,INH,Anti-TBdrugs)
✓Adherence
2/21/2023271

272. Monitoring and managing Drug-Drug interaction
oEffectofdrugscanbemodifiedbytheuseofanother
oHIV-positivewomenmaybeundertreatmentforotherconditionsbesidesHIV
oThusitisimportantthatyouknowwhatinteractionsexistbetweenthegroupof
drugsthatyouusetoprovideeffectivetreatmentforyourclients
oMostofthedrugsaremetabolizedbykidneyandliver
oEg:TDF/3TCismetabolizedbythekidney
EVF/DTG bytheliver
2/21/2023272

273. Drug-Drug Interaction
❖Rifampicin induces metabolism of NNRTIs;
NVP and EFV
❖Anticonvulsants: induce PIs and NNRTIs
❖NVP/EFV induces metabolism of estrogen containing oral
contraceptive
❖EFV may reduce effect of systemic ketoconazole
2/21/2023273

274. Treatment failure
❖Treatment failure is diagnosed when:
oNew opportunistic infections
oClinical stage 3 and 4 after 6month treatment
oCD4 count less than 250cells/mm3 or
oPersistent CD4 level less than 100 cells/mm3
2/21/2023274

275. Predisposing factors for treatment failure
oDrug resistance
oPoor treatment adherence
oMedications poorly absorbed
oOther illness or conditions
oPoor health before starting treatment
oSide effect of drugs or drug-drug interactions
oSubstance abuse
2/21/2023275

276. Nutritional Care and Support for HIV Infected
Pregnant/Lactating Women
NutrientrequirementsforanHIVinfectedpregnantorlactating
womenareTWICEthatofanon-pregnant,non-lactatingwoman!
1.ShouldfighteffectsofHIVinfectionandassociatedOIs
2.Shouldsupportoptimumfetalgrowthanddevelopment/aswell
aslactation.
2/21/2023276

277. Nutrient cont.…..
✓HowevernutrientintakeandusecanbereducedinHIVinfectedpregnantand
lactatingwomendueto:
Lossofappetite(infection,depression,sideeffectsofdrugs)
Reducedabsorption(chronicdiarrhea,andHIVrelatedintestinalcelldamage)
Impairedutilizationandstorageofnutrients
2/21/2023277

278. PMTCT during Labor and delivery
✓UseaPartographtoallowearlydetectionandmanagementofprolonged
labor
✓Artificialruptureofmembrane(ARM)increasesriskofHIVtransmission
✓Donotperformroutineepisiotomy
✓Avoidfrequentvaginalexamination
✓Donotmilktheumbilicalcordbeforecutting
2/21/2023278

279. Newborn and Postnatal care
✓Donotsuctionwithnasogastrictubeunlessthereismeconium-stainedliquor
✓Immediatelyafterbirth,wipethebabydrywithatoweltoremovematernalbodyfluids
✓GiveBCGandpoliovaccineafterbirthtoallbabiesborntoHIVinfectedmothers(as
forallinfants)
✓ProvideNVPandAZTprophylaxisforthedurationof6weeksthenNVPforthenext6-12
weeksirrespectiveofthefeedingstatus
✓HIVtestforexposedinfantat6wk(DBStest)
2/21/2023279

280. ART prophylaxis for HEI
oAZTandNVPfor6wksthenNVPfor6-12wks
oDNA-PCRmustbetestedat6wk
oNewlydiagnosedbreastfeedingmother:highriskexposedinfant
so:
➢DNA-PCRfirstdonethenputonARTifpositive
➢IfnegativestartAZTandNVPandNVPfor12wks
2/21/2023280

281. Reference
➢NationalComprehensivePMTCT/MNCH manual2021
➢WorldHealthOrganization(2016).'Mother-to-childtransmissionofHIV.
➢UNAIDS(2017)‘StartFreeStayFreeAIDSFree:2017progressreport
➢UNAIDSData(2019).
➢UNAIDS(2021).GlobalHIV&AIDSstatisticfactsheet
➢EMOH(2018).NationalconsolidatedguidelinesforcomprehensiveHIV
prevention,careandtreatment
➢LeSaoutE(2020).PMTCTofHIV.InternationalMSFworkinggroup
2/21/2023281

282. Sexually Transmitted Infections and Reproductive Tract
Infections

283. 283
Learning Objectives
Describe RTIs and STIs
Explain the public health significance of STIs
Describe the main STI pathogens
Describe risk factors for STIs
Describe STIs control strategies
Describe the challenges to STIs control

284. 284
I. Definition of Terms
Reproductive tract infections (RTIs) are infections of the genital tract
of women and men.
There are three types of RTIs:
1.Sexually transmitted infections (STIs)
Infections caused by organisms that are passed through sexual activity
with an infected partner.
More than 40 have been identified, including chlamydia, gonorrhea,
hepatitis B and C, herpes, human papillomavirus, syphilis,
trichomoniasis, and HIV.

285. 285
Definition…
2. Endogenous infections
Infections that result from an overgrowth of organisms normally present in
the vagina.
These infections are not usually sexually transmitted and include bacterial
vaginosis and candidiasis.
3. Iatrogenic infections
Infections introduced into the reproductive tract by a medical procedure
such as menstrual regulation, induced abortion, IUD insertion, or
childbirth.
This can happen if surgical instruments used in the procedure are not
properly sterilized, or if an infection already present in the lower
reproductive tract is pushed through the cervix into the upper
reproductive tract.

286. 286
Definition…
These three types of RTIs overlapand should be considered
together.
For example, some STIs, like gonorrhea or chlamydia, can be spread
in the reproductive tract if not treated prior to a procedure.
In addition, some non-sexual infections, such as candidiasis, can be
passed on through sexual activity.
Not all STIs are RTIs; and not all RTIs are sexually transmitted; STI
refers to the way of transmission whereas RTI refers to the site where
the infections develop.

287. 287
Sites of Infection: Female Anatomy
Fallopian tubes
Vulval, labial, vagina
Genital ulcers
(syphilis,chancroid,herpes),
genitalwarts
Vagina
Bacterial
vaginosis,
yeast infection,
trichomonas
Uterus
Gonorrhoea,
Chlamydia,
vaginal
bacter
Cervix
Gonorrhoea, chlamydia
herpes

288. 288
Sites of Infection: Male Anatomy
Penis, Scrotum
Genital ulcers (Syphilis,
chancroid, herpes)
Genital warts
Spermatic
cord
Epididymis
Urethra
Gonorrhea,
chlamydia
Testes

289. 289
II. Public Health Significance of STIs
Over 340 million curable, and much more incurable, STIs occur each year.
Among women, non-sexually transmitted RTIs are usually even more
common.
In developing countries, STIs and their complications rank in the top five
disease categories for which adults seek health care.
In women (15-49 years), STIs, even excluding HIV, are second only to
maternal factors as causes of disease, death, and healthy life lost.

290. 290
Public Health…
Self-reported prevalence of STIs in Ethiopia 2 % (women) and 1.5 %
(men)
The links between STIs and HIV
The presence of an untreated STI enhances both the acquisition and
transmission of HIV
STI treatment is an important HIV prevention strategy in a general population
Integration of HIV/AIDS programs with STIs prevention and care programs is
economically advantageous (similar interventions and target audiences)

291. 291
Public Health…
Clinical services offering STI care are important for providing information and education
about STIs including HIV in order to promote lower-risk behavior.
STIs can lead to the development of serious complications.
Women: cervical cancer, pelvic inflammatory disease, chronic pelvic pain, ectopic
pregnancy, and infertility.
Men: sub-fertility
Newborn: blindness and lung damage
Syphilis can result in congenital syphilis for the baby and fatal cardiac, neurological, and
other complications in adults
Genital warts can lead to genito-anal cancers

292. 292
Public Health…
Untreated gonococcal and chlamydial infections in women will result in
pelvic inflammatory disease in up to 40% of cases. One in four of these
will result in infertility.
In pregnancy, untreated early syphilis will result in a stillbirth rate of
25% and be responsible for 14% of neonatal deaths –an overall
perinatal mortality of about 40%. Syphilis prevalence in pregnant
women in Africa, for example, ranges from 4% to 15%.

293. 293
Public Health…
Human papillomavirus (HPV) causes about 500 000 cases of cervical
cancer annually with 240,000 deaths, mainly in resource-poor countries.
Worldwide, up to 4000 newborn babies become blind every year
because of eye infections attributable to untreated maternal gonococcal
and chlamydial infections.

294. 294
Public Health…
STIs constitute a huge health and economic burden, especially for
developing countries, where they account for 17 % of economic
losses due to ill-health
Herpes simplex virus type 2 (HSV-2) infection is the leading cause of
genital ulcer disease (GUD) in developing countries. Data from sub-
Saharan Africa show that 30%–80% of women and 10%–50% of men
are infected.
Throughout the world, HSV-2 seropositivity is uniformly higher in
women than in men and increases with age.

295. 295
Public Health…
HSV-2 plays an important role in the transmission of HIV infection. A
study in Mwanza, the United Republic of Tanzania, showed that 74%
of HIV infections in men and 22% in women could be attributable to
HSV-2
Hepatitis B virus (HBV),which may be transmitted sexually results
in an estimated 350 million cases of chronic hepatitis and at least
one million deaths each year from liver cirrhosis and liver cancer.
A vaccine to prevent hepatitis B infection, and thereby reduce the
incidence of liver cancer, exists

296. 296
Public Health…
The socioeconomic costs of STIs and their complications are substantial
Ranks among the top 10 reasons for healthcare visits in most developing
countries, and substantially drain both national health budgets and household
income.
Care for the sequel of STIs accounts for a large proportion of tertiary
healthcare costs
The social costs of STIs include conflict between sexual partners and domestic
violence.

297. 297
III. Main STI Pathogens
More than 30 pathogens are transmissible through sexual intercourse-
oral, anal, or vaginal.
The main sexually transmitted bacteria are:
Neisseria gonorrhoeae (causes gonorrhea)
Chlamydia trachomatis (chlamydial infections)
Treponema pallidum (causes syphilis)
Haemophilusducreyi(causes chancroid)
Klebsiella granulomatis(causes granuloma inguinale or donovanosis)

298. 298
STI Pathogens…
The main sexually transmitted viruses are:
Human immunodeficiency virus (causes AIDS)
Herpes simplex virus (causes genital herpes)
Human papillomavirus (causes genital warts)
Hepatitis B virus
Cytomegalovirus
The main parasitic organisms are:
Trichomonas vaginalis (causes vaginal trichomoniasis)
Candida albicans (causes vulvovaginitis in women; inflammation of the
glans penis and foreskin [balano-posthitis] in men).

299. 299
IV. Risk Factors for STIs
Biological factors
Behavioral factors
Social factors

300. 300
V. Why Invest in STI Prevention and Control Now?
To reduce STI-related morbidity and mortality
To prevent HIV infection
Genital ulcer diseases have been estimated to increase the risk of
transmission of HIV 50–300-fold per episode of unprotected sexual
intercourse
Improved syndromic management of STIs reduced HIV incidence by 38% in
a community intervention trial in Mwanza
Thailand also reduced HIV prevalence by effectively controlling STIs

301. 301
Why Invest…
To prevent serious complications in women
STIs are the main preventable cause of infertility
PID, ectopic pregnancy, and cervical cancer
To prevent adverse pregnancy outcome
Perintataldeaths
Spontaneous abortions
Preterm deliveries
Ophthalmia neonatorum

302. 302
Why invest…
Universal institution of an effective intervention to prevent congenital
syphilis should prevent an estimated 492 000 stillbirths and perinatal
deaths per year in Africa alone.
In terms of cost–effectiveness, in Mwanza, with a prevalence of active
syphilis of 8% in pregnant women, the cost of the intervention is estimated
to be US$ 1.44 per woman screened, US$ 20 per woman treated, and US$
10.56 per disability-adjusted life year (DALY) saved.
The cost per DALY saved from all syphilis-screening studies ranges from
US$ 4 to US$ 19

303. 303
VI. STI Control Strategies
1.Prevention by promoting safer sexual behaviors;
2. General access to quality condoms at affordable prices;
3. Promotion of early recourse to health services by people suffering
from STIs and by their partners;
4. Inclusion of STI treatment in basic health services;
5. Specific services for populations with frequent or unplanned high-
risk sexual behaviors

304. 304
Control Strategies…
6. Proper treatment of STIs, i.e. use of correct and effective medicines; treatment
of sexual partners; education and advice; reliable supply of condoms;
7. Screening of clinically asymptomatic patients;
8. Provision for counseling and voluntary testing for HIV infection;
9. Prevention and care of congenital syphilis and neonatal conjunctivitis;
10. Involvement of all relevant stakeholders, including the private sector and the
community, in the prevention of STIs and prompt contact with health services
for those requiring care.

305. 305
The Role of Clinical Services in Reducing the Burden of STIs/RTIs
People with STI/RTI
Symptomatic
Seek care
Accurate diagnosis
Correct treatment
Completed treatment
Cure

306. 306
In order to address these challenges, health providers should:
Raise awareness in the community about STIs/RTIs and how they can be
prevented
Promote early use of clinic services.
Promote safer sexual practices when counseling clients.
Detect infections that are not obvious.
Prevent iatrogenic infection
Manage symptomatic STI/RTI effectively
Counsel patients on staying uninfected after treatment.

307. 307
Traditional Approaches to STI Diagnosis
1.Etiologic diagnosis: using laboratory tests to identify the causative agent
2.Clinical diagnosis: using clinical experience to identify the symptoms
typical for a specific STI.
Even in a well-structured health system, etiological and clinical diagnoses
are problematic.
Etiologicaldiagnosisis expensive and time-consuming; it requires
special resources and delays treatment.
With a clinical diagnosis, it is easy to diagnose some STIs incorrectly and
also to miss mixed infections.

308. 308
The STI Syndromes and the Syndromic Approach to Case Management
Many different agents cause STIs.
However some of these agents give rise to similar or overlapping clinical manifestations.
The main STI syndromes are:
@ Urethral discharge
@ Genital ulcer
@ Inguinal bubo
@ Scrotal swelling
@ Vaginal discharge
@ Lower abdominal pain
@ Neonatal conjunctivitis

309. 309
Main Features of Syndromic Management
Periodic laboratory-based classification of the main causal pathogens by
the clinical syndromes they produce
Use of flow charts derived from this classification to manage a particular
syndrome
Treatment for all important causes of the syndrome
Notification and treatment of sex partners.

310. 310
Obstacles to the Provision of Services for STI Control
Decline in interest and resources for STIs prevention and control
globally in favor of ART and VCT
Lack of integration of prevention and care activities for STIs (including
HIV) into sexual and reproductive health services
Problem with syndromic Mx of women with vaginal discharge,
especially in low prevalence areas

311. 311
Obstacles to Provision of Services…
Intervention efforts to prevent STIs have failed to take into consideration
the full range of the underlying determinants
Inability to ensure consistent supplies of STI medicines and condoms
Counseling on risk reduction is also usually lacking
Inadequate participation of partners, especially communities

312. 312
Underlying Factors for Failure to Control STIs
Ignorance and lack of information on STIs perpetuate wrong
conceptions of these diseases and associated stigmatization.
Many STIs tend to be asymptomatic or otherwise unrecognized
until complications and sequelae develop, especially in women.
The stigmatization associated with STIs (and clinics that provide STI
services) constitutes an ongoing and powerful barrier to the
implementation of STI prevention and care interventions.

313. Unwanted Pregnancy and Unsafe Abortion

314. Unwanted Pregnancy

315. Unwanted Pregnancy
•Unwanted pregnancy is a pregnancy that a woman is not actively trying
to have
•It could be
–Unintended
–Unplanned
–A mistake or
–Not at the right time

316. Reasons why a woman may not want a child
•May constrain her opportunities
➢Education
➢Employment
•Unwanted marriage
•Stigma
•Abandonment

317. Why unwanted pregnancy happen?
•Main reasons include
–Failure of contraceptive and family planning delivery systems
•Lack of information
•Lack of access
•Social/cultural/Religious barriers
–Violence
–Rape/Incest
–Lack of knowledge of sexuality and reproduction
–The method they were using failed.

318. Who is at risk of Unwanted pregnancy
•Married women
•Single women
•Adolescents and schoolgirls
•Rich and poor
•From Urban/Rural
All women are at risk!!!

319. The fate of women with unwanted pregnancies
•Increased morbidity/mortality
–Unsafe abortion
•Maternal death
•Complications of unsafe abortion
•Psycho-social problem
–Emotional
–Financial
–Physical

320. Why do women resort to unsafe abortion
•Restrictive laws
•Privacy
•Providers’ attitude toward safe abortion
•Other factors
–Provided in a special setup

321. Prevention Of Unwanted Pregnancy and Unsafe abortion
•Education on Sexuality and Reproductive Health
•Universal access to family planning
–Information
–Service
•Access to safe abortion

322. Grounds on Which Abortion is Permitted, revised abortion law of Ethiopia,
(House of Parliament, 2005)
When the pregnancy puts the woman’s life at risk
Fetalimpairment or deformity
When pregnancy follows Rape or incest (based on the woman’s complaint
only)
When pregnancy occurs in minors (stated maternal age <18 years)
The woman is physically and mentally unable to care for the would-be-
born child
322

323. Key elements of post-abortion care include:
1. Treatment of incomplete and unsafe abortion;
2. Counselling;
3. Family planning services;
4. Links to comprehensive reproductive health services; and
5. Community and service provider partnerships.
323