Reproductive health

Definition and components of reproductive health?
Demographic trends and fertility determinants
Family planning
Impact of reproductive patterns on child health
Impact of reproductive patterns on women health
Mechanisms to reduce morbidity and mortality

1. Reproductive health By: Adam F. Izzeldin ; BPEH, MPH, PhD candidate. Department of International Health, TMDU

2. Contents Definition and components of reproductive health? Demographic trends and fertility determinants Family planning Impact of reproductive patterns on child health Impact of reproductive patterns on women health Contents Mechanisms to reduce morbidity and mortality.

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

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

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

6. Demographic trends and fertility determinants World population reached 1 billion just after 1800. But it took less 125 years to add the second billion in 1930. In 1960 the world passed the third billion. Within 40 years ahead the population doubled to be 6 billions in 2000. In year 2010 the world population reached 7 bilion . The majority of this expansion has taken place in developing countries. The encouraging news is that the rate of growth is declining since 1960.

7. World population growth Source: United nation population division

8. Population size by continent, 1950-2100

9. The world population growth rate 2010

10. The process of fertility Menarche Start of marriage Birth of woman Effective reproductive span Sterility Marriage Marriage dissolution Death of woman B3 B1 B2 B last End of exposure to risk B2 Resumption of menses conception Fetal loss conception B3 Postpartum amenorrhea Time to conception Time to conception pregnancy

11. Deliberate control of fertility Reducing the effective reproductive span through postponement of marriage or interrupted marriage or by sterilization that ends reproductive capacity early. Using contraception, which increases the time to conception. Abortion, which increases the time added to birth interval by pregnancies that do not lead to live birth

12. The effect on fertility of the proximate determinants: Bongaart’s Indices The index of postpartum infecundity: The proportion of potential fertility, TF, when the average of postpartum period of the population of interest is taken into account. The index of abortion: The proportion of TF, after postpartum first taken into account. The index of contraception: The proportion of TF, after the effect of postpartum infecundity and induced abortion taken into account. The index of marriage: The proportion of TF, after the first three factors are considered. TFR= TF

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

14. Family planning methods Region Sterilization Pill IUD Condom Total Female Male World 21.0 4.0 7.0 15.0 5.0 61.0 Low and middle income countries Africa 2.0 0.1 7.0 5.0 1.0 26.0 Asia 25.0 4.0 5.0 18.0 4.0 64.0 Latin America 31.0 2.0 13.0 8.0 4.0 70.0 Oceania 12.0 9.0 21.0 2.0 9.0 59.0 Industrialized region Japan 3.0 0.6 0.8 1.5 43.0 56.0 Europe 4.0 2.0 16.0 15.0 10.0 67.0 Northern America 23.0 14.0 15.0 1.0 13.0 76.0 New Zealand 14.0 19.3 20.5 3.3 11.0 74.0

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

16. Consequences of unintended pregnancy Abortion: represents 20% of all pregnancies (WHO estimates 20 million unsafe abortion annually accounts from 13% of maternal deaths) Poor infant health with high morbidity and mortality. Lower investment in human capital (allocation f resources for education and health).

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

18. Intervention levels of family planning Information, education, and communication Community-based distribution Social marketing of condoms and pills Counseling/ screening for contraception Counseling/ referral for menstrual regulation or abortion Inject able contraceptive/ IUD/ counseling and treatment of contraceptive side effects menstrual regulation or vacuum aspiration abortion Surgical contraception/ post abortion counseling and contraception counseling and treatment of contraceptive side effects Surgical contraception Abortion through 20 weeks post abortion counseling and contraception Family planning community Health center District Hospital Health post

19. Fostering village-based and household services (outreach) Diagram Awareness and motivation ( mass media, focused programs) Strategy 1 Strategy 3 Strategy 2 Improving coverage and quality of services ( 5 miles clinics, free of charge sterilization, home service) Community development and demand creation (improving status of women through other program such as micro-credit and education ). Strategy 4 Strategies of Bangladesh Family planning

20. Impact of reproductive patterns on child health Reproductive pattern Mechanism through which child health affected First born child Higher frequency of death (parents less experienced in child care, poor intrauterine growth) Higher-order children Cumulative maternal injuries “ maternal depletion syndrome” leads to poor intrauterine growth. Large families Competition for limited resources (disproportionate girls) Child born to very young mother Inadequate development of reproductive system causes maternal risks, and inexperience in prenatal care and delivery Child born to older mother Greater risk of birth trauma and genetic abnormality Short interbirth intervals Inadequate maternal recovery (depletion);similar -age siblings competition; termination of breastfeeding; low-birth, infections Unwantedness Conscious or unconscious neglect; child born in stressful situation Maternal death or illness Early termination of breastfeeding; no maternal care; disease may be passed to child Contraceptive use Hormonal contraception may interrupt braestfeeding

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

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

23. Maternal mortality risks In sub-Saharan Africa and South Asia, maternal mortality ratio of 800 maternal deaths per 100,000 live births have been reported. The disparity between low- and middle-income and high-income countries is much greater for maternal mortality ( 20 times higher risk of maternal death per pregnancy) than infant mortality ( 10 time s higher risk of infant death per pregnancy). Life-time risk of maternal mortality vary from 1/75 in low- and middle-income countries to 1/7,300 in high-income countries. Maternal mortality ratios are 50 times higher (450 death/100,000 LB in low- and middle-income countries vs. 9 deaths/100,000 LB in high-income countries )

24. Total Fertility R ate, Maternal M ortality R atios, and Lifetime Risk of Maternal D eath by region,2005. source: P opulation R eference Bureau (2008) Region Total Fertility Rate (Birth per woman) Maternal Mortality Ratio (Deaths per 100,000 LB) Maternal Deaths Lifetime Risk Death per year World 2.6 400 1 in 92 536,000 Industrialized countries 1.7 9 1 in 7,300 960 Low- and middle-income 2.7 450 1 in 75 533,000 Africa 4.8 820 1 in 26 276,000 Asia 2.3 330 1 in 120 241,000 Latin America and Caribbean 2.3 130 1 in 290 15,000

25. Direct and indirect causes of maternal mortality and morbidity D irect : related to pregnancy or postpartum periods (hemorrhage 25%, sepsis 15%, eclampsia 12%, complications of unsafe abortion 13%, obstructed labor and others). Indirect : related to conditions precede, but aggravated by, pregnancy ( anemia, diabetes, malaria, tuberculosis, cardiac diseases, hepatitis, and increasingly HIV) WHO,2005

26. Impact of reproductive patterns on women health Reproductive pattern Mechanism through which maternal health is affected Number of pregnancies Each pregnancy carries a risk of morbidity and mortality Higher-risk pregnancies First-time mothers 2-4 higher risk for obstructed labor, induced hypertension, obstetric complications due to initial adaptation High-order pregnancies Hemorrhage and uterine rupture and reproductive injuries Pregnancy at very young maternal ages Physiological immature reproductive system and reduced timely care seeking. Pregnancy at old maternal ages Body in poor condition for pregnancy and child birth Short interbirth intervals Inadequate time to rebuild nutritional stores and regain energy level. Unwanted pregnancies ending in unsafe abortions Increased exposure to injuries, infections, hemorrhages, and deaths Pregnancy for women already in poor health Aggravated health conditions.

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

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

29. Thank you for listening