rh 2. family and reproductuve healt nepalh

family health

1. Reproductive health Unit 2

2. Reproductive Health Introduction Reproductive health (RH) is a crucial aspect of general health and is central to human development. Reproductive health is not a new issue in health science. The World Health Assembly recognized the public health importance and social and economic consequences of reproductive health as early as 1965 .

3. Introduction contd … WHO seeks to enhance the capability of countries to define needs and priorities in reproductive health. During 1970s, most of the family planning programs were implemented to reduce population growth. Since 1980 the international women’s health movement started urging that, woman’s rights and wellbeing be realized.

4. Definition of Reproductive Health RH is a state of complete physical, mental, and social well-being in all matters relating to the reproductive system and to its functions and processes. RH is the collection of methods, techniques and services that contribute to reproductive health and well being by preventing and solving reproductive health problems.

5. Definition of Reproductive Health RH also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not only counseling and care related to reproduction and sexually transmitted diseases.

6. Evolution of reproductive health service in Nepal Reproductive health is not a new program for Nepal, but it has adopted different models in the past forty years to reduce high fertility, and high infant mortality and maternal mortality rates. The original model of RH in 1970 focused mainly on fertility control.

7. Evolution of reproductive health service in Nepal Contd ……… This model ignored individual needs at different phases of human reproduction. In spite of great efforts and investment, fertility regulation could not be achieved much with this model. In 1980, the relationship between fertility and infant and child mortality was given importance.

8. Evolution of reproductive health service in Nepal Contd ……… This model ignored individual needs at different phases of human reproduction. In spite of great efforts and investment, fertility regulation could not be achieved much with this model. In 1980, the relationship between fertility and infant and child mortality was given importance.

9. Evolution of reproductive health service in Nepal Contd ……… However, this model also ignored women’s personal needs at different stages of life. A woman is much more than an agent of reproduction. Women’s reproductive health is only part of the totality of women’s health.

10. Evolution of reproductive health service in Nepal Contd … However, this model also ignored women’s personal needs at different stages of life. A woman is much more than an agent of reproduction. Women’s reproductive health is only part of the totality of women’s health.

11. Evolution of reproductive health service in Nepal Contd ……… In this context, a new paradigm of RH has been emerged at the International Conference of Population and Development (ICPD) 1994. This new model encompasses(cover) broader concept of RH that has considered basic human rights, human development and individual wellbeing at all stages of life.

12. Evolution of reproductive health service in Nepal Contd ……… Reproductive health is not a new program but rather a new approach, which has integrated the existing safe mother hood, family planning, HIV/AIDS, STI, child survival, post-abortion care, and adolescent reproductive health program with a holistic life cycle approach.

13. Evolution of reproductive health service in Nepal Contd ……… Nepal is a signatory of the Program of Actions of the International Conference on Population and Development (ICPD, 1994). And has committed itself to improve reproductive health status throughout the country. So, Nepal’s Government has endorsed the ICPD program of action as well as the 1995 WHO global RH strategy, both of which serve as a basis for Nepal’s national RH strategy.

14. Evolution of reproductive health service in Nepal Contd ……… Family planning (private sector in 1958, public policy in 1965) Family planning and MCH program in 1968 STD and AIDS in 1988 Safe motherhood policy in 1992 National Reproductive Health Strategy in 1998

15. Important human rights related to RH Right to lead a responsible and satisfied sex life. Right to reproduce and freedom to decide when and how often to do so. Right to be informed about advantages, possible risks and side effects.

16. Important human rights related to RH Contd …. Right to have free, equal and unhindered access to safe, effective, affordable, and acceptable method of fertility regulation. Right to get access to appropriate health service of good quality to go through safe pregnancy and child birth.

17. International Conference on Population and Development (ICPD), 1994 Held in Cairo, Egypt, from 5 to 13 September 1994. Delegations from 179 States took part in negotiations for the next 20 years. Discussion was held on population issues, including immigration, infant mortality, birth control, FP, and education of women.

18. Guiding principles of RH developed by ICPD Empowerment of women Involvement of women, women’s organization Promotion of men’s participation in RH/FP Assure highest level of quality of care Integrated services Make available effective methods of FP.

19. Concept of reproductive health Reproductive health does not start out from a list of diseases or problems - sexually transmitted diseases, maternal mortality - or from a list of programs - maternal and child health, safe motherhood, family planning. Reproductive health instead must be understood in the context of relationships: fulfillment and risk; the opportunity to have a desired child or alternatively, to avoid unwanted or unsafe pregnancy.

20. Concept of reproductive health Contd Reproductive health contributes enormously to physical and psychosocial comfort and closeness, and to personal and social maturation. Poor reproductive health is frequently associated with disease, abuse, exploitation, unwanted pregnancy, and death.

21. Concept of reproductive health The most significant achievement of the Cairo Conference was to place people firmly at the centre of development efforts, as protagonist in their own reproductive health and lives rather than as objects of external interventions. The aim of interventions is to enhance reproductive health and promote reproductive rights rather than population policies and fertility control.

22. Concept of reproductive health This implies: The empowerment of women (through better access to education); The involvement of women and young people in the development and implementation of programs and services; Reaching out to the poor, the marginalized and the excluded; And assuming greater responsibility for reproductive health on the part of men.

23. Components of Reproductive Health Includes services designed to help individuals attain and maintain state of RH by preventing and solving RH problems. Positive RH means that individuals can manage their own sexuality and have unrestricted access to full range of RH care. RH is a critical component of women’s general health.

24. Components of Reproductive Health Focuses on: Right of all women and men to be informed. To have access to safe, effective, affordable, and acceptable methods of FP of their choice. To have access to appropriate health care services that enable women to safely go through pregnancy and childbirth

25. Components of Reproductive Health Family planning Safe motherhood Child health (newborn care) Prevention and mgmt of complications of abortion Prevention and control of STI and HIV/AIDS

26. Components of Reproductive Health cont Prevention and management of sub fertility Adolescent reproductive health Problems of elderly women Violence against women (VAW)

27. 1. Family planning In the past, family planning was considered as a means to control population and to prevent unwanted pregnancy. But now, it has a lots of benefits for improving overall status of mothers, children, families and quality of life of people.

28. Family planning A woman’s ability to space or limit the number of her pregnancies has a direct impact on her health and well-being as well as the outcome of her pregnancy. It also improve the social and economic circumstances of women and their families. The use of family planning methods contributes to women’s empowerment, schooling and economic stability.

29. objectives The overall objectives of Nepal family planning is to improve the health status of all people through informed choice on accessing and utilizing client- centered quality voluntary FP services . There are some specific adjectives which are given below To increase access to and use of quality FB services that is safe, effective and acceptable to individuals and couple. A special focus is on increasing access in rural and remote places and to poor, dalit , and other marginalized people with high unmet needs and to postpartum and post- abortion women, the wives of labour migrants and adolescents.

30. 2.To increase and sustain contraceptives use and reduce unmet need of FP, unintended pregnancies , and contraception discontinuation. 3. To create an enabling environment for increasing access of quality FP services to men and women including adolescents. 4. To increase the demand for FP services by implementing strategies behaviour change communication activities.

31. Cont … Enabling environment: Strengthen the enabling environment for FP 2. Demand generation: Increase health care seeking behavior among population with high unmeet need for modern contraception. 3. Service delivery: enhance FP services delivery including commodities to respond to the needs of marginalized people , rural people migrants , adolescents and other group 4. Capacity building: strengthen the capacity of services providers to expand FP service delivery. 5.Research and innovation: strength en the evidence base for programme implementation through research and innovation

32. Benefits of Family planning For woman: Better health/protection from certain diseases like STI, HIV/AIDS etc Prevention of unsafe abortion Less physical/emotional/economic strain Greater care to each child Improved quality of life

33. Benefits of Family planning Cont … For children: Better health More food and other resources available Greater opportunity for economical support from parents Better opportunity for education

34. For men: Can provide protection from STI/HIV Less emotional and economic strain Freedom of decision Improved quality of life

35. For family: Less emotional and financial strain Increased economic opportunities Increased education opportunities for children More energy for household activities More energy for personal development and community activities

36. For nation: Reduced strain on environmental resources. Reduced strain on community resources Greater participation by individual in community affairs

37. Gap of FP program in Nepal Low functional knowledge on family planning Low male participation High unmet need Concept of family planning has limited scope Low contraceptive prevalence rate (CPR) among the poor, rural, mountains and hilly areas.

38. Activities needed to improve FP service Promote spacing methods of contraceptives particularly long acting method. Well balanced FP methods rather than only one or two methods. Strengthen integrated service approach. Reposition FP program and shifting the focus. Strengthen and expand training for service provider

39. Activities needed to improve FP service Expand the number of service delivery site. Increase public and private partnership (PPP). Address misconception and rumors Increase male involvement

40. Activities needed to improve FP service contd Promote use of family planning method to reduce the incidence of abortion. Implement special program for the under privileged community

41. Major Activities in FY 2079/80 ●Provision of long-acting reversible services (LARCs like- Intra-uterine contraceptive device (IUCD) and Implant) ●Voluntary Surgical Contraception (VSC) camps and institutional base. ●Provision of regular comprehensive FP service including post-partum and post abortion FP services. ●Micro planning for addressing unmet need of FP in hard to reach and underserved communities.

42. Major Activities in FY 2079/80 ●Integration of FP with other SRH service (Nutrition, Immunization) ●Satellite clinic services for long-acting reversible contraceptives ●Contraceptive update for Obstetrician/Gynecologist, nurses and concerned key stakeholders. ●Provision of emergency contraceptive pill (ECP) services through all public health facilities and FCHVs. ●High level policy dialogue on family planning program at federal level

43. Major Activities in FY 2079/80 Interaction with organization working in people with disabilities to improve sexual and reproductive health (SRH) access. ● Interaction program on FP and RH including adolescents’ need of SRH with pharmacist and marginalized communities. ● Public Private Partnership for family planning services in designated hospitals and medical colleges. ● New methods: Emergency Contraceptive Pills (ECP) and Sayana Press ● Initiation and drafting of FP Sustainability Roadmap and FP Costed Implementation Plan up to 2030.

44. 2. Safe motherhood The main thrust of National Safe Motherhood Programme is to reduce maternal and neo-natal mortality by addressing the high rates of death and disability caused by the complications of pregnancy and childbirth. The global experience shows that all pregnancies are at risk and complications during pregnancy, delivery and post natal and maternal deaths are difficult to predict.

45. Cont … The goal of the National Safe Motherhood Program is to reduce maternal and neonatal morbidity and mortality and to improve the maternal and neonatal health through preventive and promotive activities as well as by addressing avoidable factors that cause death during pregnancy, childbirth and postpartum period. Evidence suggests that three delays are important factors for maternal and newborn morbidity and mortality in Nepal (delays in seeking care, reaching care and receiving care

46. Major stratigies Promoting birth preparedness and complication readiness including awareness raising and improving preparedness for funds, transport and blood transfusion.

47. Cont … The policy on skilled birth attendants (2006) highlights the importance of skilled birth attendance (SBA) at all births and embodies the government’s commitment to train and deploy doctors, nurses and ANMs with the required skills across the country

48. Cont …

49. Main strategies of the Safe Motherhood Programme Promoting inter-sectoral coordination and collaboration at Federal, Provincial, districts and Local levels to ensure commitment and action for promoting safe motherhood with a focus on poor and excluded groups

50. Cont … Strengthening and expanding delivery by skilled birth attendants and providing basic and comprehensive obstetric care services at all levels. Interventions include: developing the infrastructure for delivery and emergency obstetric care; standardizing basic maternity care and emergency obstetric care at appropriate levels of the health care system

51. Cont…

52. Cont… Strengthening community-based awareness on birth preparedness and complication readiness through FCHVs and increasing access to maternal health information and services Supporting activities that raise the status of women in society Promoting research on safe motherhood to contribute to improved planning, higher quality services and more cost-effective interventions

53. Major activities Community level maternal and newborn health interventions Rural Ultrasound Programme Reproductive health morbidity prevention and management programme Management of pelvic organ prolapse and Obstetric Fistula Cervical cancer screening and prevention training Human resources Expansion and quality improvement of service delivery sites Onsite clinical coaching and mentoring MNH readiness Hospital and BC/BEONC Quality Improvement PNC home visit(microplanning for PNC)

54. Cont… Emergency referral funds Safe abortion services Onsite clinical coaching and mentoring Obstetric first aid orientations NyanoJhola Programme Aama and Free Newborn Programme

55. Provisions of the Aama Programme and Newborn Programme Aama programme provision a. For women delivering their babies in health institutions: Transport incentive for institutional delivery: Cash payment to women immediately after institutional delivery (NPR 3,000 in mountains, NPR 2,000 in hills and NPR 1000 in Tarai districts). Incentive for 4 ANC visits: A cash payment of NPR 800 to women on completion of four ANC visits at 4, 6, 8 and 9 months of pregnancy, institutional delivery and postnatal care.

56. Cont … Free institutional delivery services: A payment to health facilities for providing free delivery care. For a normal delivery health facilities with less than 25 beds receive NPR 1,000 and health facilities with 25 or more beds receive NPR 1,500 For complicated deliveries health facilities receive NPR 3,000 and for C- sections (surgery) NPR 7,000. Ten types of complications (antepartum haemorrhage (APH) requiring blood transfusion, postpartum haemorrhage (PPH) requiring blood transfusion or manual removal of placenta (MRP) or exploration, severe pre-eclampsia, eclampsia, MRP for retained placenta,

57. Cont … Puerperal sepsis, instrumental delivery, and management of abortion complications requiring blood transfusion) and admission longer than 24 hours with IV antibiotics for sepsis are included as complicated deliveries. Anti-D administration for RH negative is reimbursed NPR 5,000. Laparotomies for perforation due to abortion, elective or emergency C-sections, laparotomy for ectopic pregnancies and ruptured uterus are reimbursed NPR 7,000 to both public and private facilities.

58. Cont..

59. Newborn Care Programme Provision For sick newborns: There are four different types of package (Package 0, Package A, B, and Package C) for sick newborns case management. Sick newborn care management cost is reimbursed to health facility.. Health facilities can claim a maximum of NPR 8,000 (packages A+B+C), depending on medicines, diagnostic and treatment services provided .

60. Cont …

61. Pillars/elements of safe motherhood

62. Major activities carried out

63. Antenatal care

64. Delivery care

65. Postnatal care Three postnatal visits- within 24 hrs of delivery,3 rd day and 7 th day of delivery.. Identification and management of mothers and newborn in complications of postnatal period and referral. Promotion of exclusive breastfeeding. Personal hygiene and nutrition education, post‐natal vitamin A and iron supplementation for the mothers. Immunization of newborns. Post‐natal family planning counseling and services.

66. Cont … Pregnancy outcomes: Of total pregnancies, 81% were live births, 9% were induced abortions, 9% were miscarriages, and 1% were stillbirths.(NDHS 2016) Delivery: Fifty-eight percent of deliveries are conducted by skilled birth attendants, and 57% of deliveries take place in a health facility. Protection against neonatal tetanus: Eighty-nine percent of the most recent births to women in the 5 years before the survey were protected against neonatal tetanus. Perinatal mortality: The perinatal mortality rate is 31 deaths per 1,000 pregnancies.(NDHS 2016)

67. Cont … Maternal mortality: The maternal mortality ratio is 239 deaths per 100,000 live births during the 7 years preceding the survey. Lifetime risk of maternal death: In Nepal, 1 woman in 167 can be expected to have a maternal death while age 15 to 49.

68. Cont … The percentage of pregnant women attending at least 4 ANC visits as per the protocol is 55.4 percent in Fiscal Year 207/78, a slight increment of previous Fiscal Year (52.4%). The visit percent are 52.8, 49.7, 55.9 and 52.6 percent in FY 2073/74, 2074/75, 2075/76 and 2076/77 respectively

69. Cont … The Institutional deliveries as percentage of expected live births also has little bit increased to 55.4 percent in 2077/78 from 52.6 in FY 2076/77. The percentage of deliveries conducted through cesarean section (CS) is in increasing trend which is 17.6 percent in FY 2073/74, 18.57 percent in FY 2074/75, 18.88 percent in FY 2075/76 and 20.53 percent in FY 2076/77. There is a slight decerase in FY 2077/78 (20.49 %). The percentage of births attended by SBA increased to 62.3 percent in FY 2076/77 from 60 percent FY 2075/76 and 52 percent from FY 2074/75. The proportion of mothers attending three PNC visits as per the protocol increased remarkably from 18.8percent in FY 2076/77 to 25.1 percent in FY 2077/78.

70. Newborn care Health education and behaviour change communication on essential newborn care practices. Identification of neonatal danger signs and timely referral to the appropriate health facility. Delivery by skilled birth attendant both at home and health facility. Immediate newborn care and newborn resuscitation. Community based newborn care.

71. Strengthening essential obstetric care: BEOC, CEOC BEOC provides means to manage emergency obstetric complications. Also includes procedures for early detection and treatment to prevent the progression of problem. Covers management of pregnancy complications by assisted vaginal delivery, manual removal of placenta, removal of retained products of conception, and administration of parental drugs( for PPH, infection, pre eclampsia and eclampsia ), resuscitation of newborn and referral.

72. Strengthening essential obstetric care: BEOC, CEOC Contd……… Emergency obstetric care (EmOC) is a subset of EOC and responds to unexpected complications such as hemorrhage and obstructed labor. CEOC includes services at first referral level and includes surgery, anesthesia and blood transfusion along with BEOC functions.

73. Safe abortion services (SAS) Only listed doctors/health workers can provide safe abortion services at listed health facilities, with the consent of women and according to national standard. More and more women are seeking safe abortion services. Safe abortion service is seen as an effective way to avoid service interruption due to unavailability of provider.

74. Safe abortion services (SAS) Contd… The safe abortion service has slightly decreased in FY 2077/78 in comparison to last FY 2076/77. Abortion statics shows a decreasing trend from FY 2074/75. A total of 79,952 women have received safe abortion service in FY 2077/78. The figures were 87,869 in FY 2076/77; 95,746 in FY 2075/76 and 98,640 in 2074/75 showing the decreasing trend over the years.

75. Cont…. The first week and month of the newborn’s life is a time of risk. About 2/3 rd of all newborn deaths happen in the first 7 days. Newborn care takes place in homes, health care facilities and in community. The care received during the first hour, day and week of life can determine health of the newborn.

76. Essential newborn care (ENC) All babies require basic care to help ensure their survival and wellbeing. Comprehensive strategy designed to improve the health of newborns through interventions before conception, during pregnancy, at and soon after birth, and in postnatal period.

77. Essential newborn care (ENC) ENC comprises Basic preventive newborn care - care before and during pregnancy, clean delivery practices, temperature maintenance, eye and cord care, and early and exclusive breastfeeding. Early detection of problems or danger signs and appropriate referral and care seeking Treatment of key problems such as sepsis and birth asphyxia.

78. Essential newborn care Major causes of newborn deaths in Nepal are infection, birth asphyxia, preterm birth, and hypothermia. Three-quarters of all newborn deaths occur during the first week of life, 25–45% in the first 24 hours. Over the past decade, Nepal, however, has had success in reduction of under-five mortality.

79. Community based newborn care program (CB-NCP) MoHP has incorporated newborn health as an integral component of safe motherhood efforts since late 1990s. National Neonatal Health Strategy was endorsed in 2004. In 2004, Newborn component was added to CB‐IMCI.( Integrated Management of Childhood Illness (IMCI) Community Based Newborn Care Program has been developed in 2007.

80. Program goal, Program objectives Goal:To improve the health and survival of newborn babies. To prevent and manage newborn infections. To prevent and manage hypothermia and low birth weight (LBW) babies. To manage post delivery asphyxia in newborns. To develop an effective system for referral of sick newborns.

81. Program strategies District planning District level orientation to all relevant stakeholders. Training for different levels. Central and regional level training for trainers and participants: doctors, nurses, skilled birth attendants (SBA), senior staffs of district health and population and technical staff of partner organizations.

82. Program strategies

83. Interventions included in the package

84. Cont…

85. Cont…

86. Cont … This integrated package of child‐health intervention addresses the major problems of sick newborn such as birth asphyxia, bacterial infection, jaundice, hypothermia, low birthweight, counseling of breastfeeding. It also maintains its aim to address major childhood illnesses like Pneumonia, Diarrhea, Malaria, Measles and Malnutrition among under 5 year’s children in a holistic way.

87. Abortion care ABORTION CARE

88. Status of abortion

89. ABORTION CARE Expulsion of fetus either spontaneously or by induction before the 22 week of pregnancy. Abortion may be safe or unsafe. Safe abortions are those performed in early pregnancy by well trained practitioners using medical and surgical methods. Mortality and morbidity rates are generally very low.

90. CONT… Unsafe abortion was recognized as a major public health problem and abortion related service was defined as an essential element of RH care by ICPD and FWCW. WHO issued technical guidance in 2003 to strengthen the capacity of health systems to provide CAC and PAC Now, many technological options for unwanted pregnancy exist including emergency contraception, vacuum aspiration and medical abortion. National RH strategy has accepted prevention and management of abortion as a component of integrated RH.

91. Unsafe abortion Procedure for terminating an unwanted pregnancy either by a person lacking the necessary skills or in an environment lacking minimum medical standard or both. Result of lack of knowledge, inaccessible health service, and legal restrictions, majority of women or family members choose to do unsafe abortion. An important cause of preventable maternal mortality and morbidity.

92. Causes of unsafe abortion Inability of women and adolescents to continue with contraceptive methods. Willingness of families to delay childbearing, but no access to contraceptives. Rape and other forms of sexual violence that are prevalent in conflict affected communities (lawlessness).

93. Immediate complications of Unsafe Abortion

94. Late/Long term complications of Unsafe Abortion

95. Government’s Efforts

96. CONT…

97. Availability of safe abortion in Nepal

98. CONT… Medical abortion is widely available in Nepal. As per government guide lines MA services (comb pack of mifepristone 200g and misoprostol 800mcg) is providing up to 10 weeks from last menstrual period through SBA

99. Cont… Bimala Pandey MEDICINE DOSE ROUTE TIME Mifepristone 200mg orally First day misoprostol 800mcg Sublingual\ buccal vaginal After 24 to 48 hours using Mifepristone

100. CONT… Surgical abortion Two types of surgical abortion services are practiced in Nepal Mauual vaccum aspiration (MVA) MVA is a method by which the content of the uterus are evacuated through a plastic or metal cannula that is attached to a vacuum source. This method is used up to 12 weeks of gestational age.

101. CONT…

102. Comprehensive post abortion care includes

103. Current situation Among the total safe abortion users, around 9% of the women were aged below 20 years. The highest number women aged less than 20 years who received safe abortion were from Bagmati province while lowest number of that aged group were from Karnali province. Among the total medical abortion, 11% were of aged less than 20 years and among the total surgical abortion, 8% were aged less than 20 years.

104. Post Abortion Contraception The post abortion contraception service has increased from 72.7% in 2076/77 to 76.7% in FY 2077/78. The share of the post abortion contraceptive service after using medical method was 58.6% and was 18.1% after using the surgical method. The acceptance of Short Acting Reversible Contraceptive (SARC) is higher(61.98%) in comparison to long-acting reversible contraceptive and permanent method (LARCPM) (14.72%).

105. Ways to improve safe abortion services in Nepal Expansion of safe abortion service in hard to reach areas. Strengthen counseling and availability of post abortion contraception Develop new strategies to streamline SAS through private clinics. Initiate pre-services training to different cardre ( core group especially of trained personnel able to assume control and to train other)  broadly of health professionals. Conduct operative researches to strengthen quality of SAS and increase access to safe abortion by disadvantaged groups\unreached areas.

106. INFERTILITY

107. INTRODUCTION Subfertility is defined as a failure to conceive within 1 or more years of regular unprotected coitus. Incindence It affects 13% to 15% of couples worldwide. In the United Kingdom, it is estimated that one in six couples would complaint of infertility.

108. Cont …

109. Cont …

110. CausCauses of Subfertility in menes of Subfertility in men

111. Cont…

112. Causes of subfertility in women

113. Causes of subfertility in women

114. Causes of subfertility in women

115. Prevention of sub-fertility Prevention of STI & RTI . Prevention from other infections such as post abortion infection, post partum infections etc Maintain healthy practices: balanced diet, avoid fatty food and intake of excessive alcohol, smoking and drug.

116. Prevention of sub-fertility Avoid exposure or use of chemicals. Avoid using unnecessary drugs. Protect scrotum from heat exposure.

117. Subfertility management Both partners should be seen together. Privacy and sufficient clinical time. Classical history taking with emphasis on exploring a couple’s anxieties. Counseling is very important and essential.

118. subfertility management Routine examination is not necessary unless indicated by the history. Each stage in the investigation and treatment of subfertility should be fully explained to the couple. Written information in a range of languages should be available where appropriate. Environmental factors can affect fertility and therefore an occupational history should be taken.

119. subfertility management The management of the individual couple should always be discussed in the context of their particular clinical situation. Patients should be fully involved in decisions regarding their treatment. Couples should also have access to infertility counselors outside the clinical team, and to patient support groups.

120. What is the success rate of treatment Over half of the couples with more than 2 years of infertility eventually become successful in achieving pregnancy. Infertility treatment and protocols Timing of intercourse Hormone therapy Intrauterine insemination (IUI) In vitro fertilizations(IVF-ET) with embryo transfer Gamate intra fallopian transfer(GIFT) Intra cytoplasmic sperm injection(ICSI)

121. Gamete intrafallopian transfer (GIFT) is  a three-step procedure that involves removing the eggs, combining them with sperm, and immediately placing them in the fallopian tubes, where the egg is fertilized ntrauterine insemination (IUI) — a type of artificial insemination — is a procedure for treating infertility. Sperm that have been washed and concentrated are placed directly in your uterus around the time your ovary releases one or more eggs to be fertilized.

122. GIFT

123. CONT… I ntracytoplasmic sperm injection (ICSI) is  an infertility treatment . It involves injecting live sperm into a person's eggs in a laboratory. This procedure can create an embryo (fertilized egg). ICSI is a form of in vitro fertilization (IVF)

124. An  embryo transfer  is the last part of the in vitro fertilization (IVF) process. During IVF, fertility medications are used to stimulate the ovaries into releasing healthy eggs. These eggs are then removed from a woman's ovaries and fertilized in a lab.

125. Fact sheet Users of SAS increased by 2,728 cases in FY 2079/80 (93,463) as compared to FY 2078/79 (90,733); from FY 2077/78 (79,952)

126. Adolescent Sexual and Reproductive Health (ASRH) National Adolescent Health and Development (NAHD) Strategy, 2074/75 (2018) Vision: To enable all adolescents to be healthy, happy, competent and responsible. Mission: Maximum use of the available methods and estMaximum use of the available methods and establishing strong bond between the concerned parties and developing strategy with the view of securing the health and development of adolescents.

127. Adolescent Sexual and Reproductive Health (ASRH) Adolescents aged 10 to 19 make up 24% (6.4 million) of Nepal’s population, with 17% of girls aged 15-19 already mothers or pregnant. Only 14.2% of currently married adolescents use modern contraceptives. Nepal, a pioneer in South Asia, endorsed its first National Adolescent Health and Development (NAHD) Strategy in 2056/57 (2000), later revised in 2074/75 (2018) to address evolving adolescent issues. GoN has the national strategy for adolescent health and strategy to enable and prioritize adolescent health issues including sexual and reproductive health.

128. Strategic Principles and Direction

129. Elements/components of care Counseling and education Prevention and management of STIs (including HIV/HBV). Counseling and education, with referral or provision of services for pregnancy prevention and management and FP. Linkages and referrals to other reproductive health care and other facilities.

130. Major Activities Conducted in FY 2079/80 ● Expansion of adolescent friendly health facilities ● Certification of adolescent friendly health facilities ● Updated Adolescent Friendly Sexual Reproductive Health Guideline

131. Scale-up of adolescent friendly service Adolescent friendly health services operation guideline has envisioned to gradually develop all health facilities as Adolescent Friendly Service sites. As per Adolescent RH guideline 2079, Adolescent Health Coordination Committees have been established in all the local levels. It regularly discusses adolescent health related issues and addresses them.

132. Certification of adolescents friendly sites In FY 2079/80, adolescent friendly health facility implementation guideline 2079 was developed and endorsed. As of 2079/80, nearly 287 health facilities are certified as adolescent friendly service sites

133. Targets: To make all health facilities as adolescent friendly as per the envision of National Health policy (2014) and NHSS (2016-2021) To ensure universal access to ASRH services, the Nepal Health Sector Strategy Implementation Plan (2016-2021) aims to: Bimala Pandey

134. scale up Adolescent Friendly Service (AFS) to all health facilities; • behavioral skill focused ASRH training to 5,000 Health Service Providers and • more than 100 health facilities to be certified with quality AFS by 2021 Bimala Pandey

135. Programe of ASRH Scale-up of Adolescent Friendly Service Strengthening Health facilities for AFS 1.ASRH Clinical Training site development 2.Competency based ASRH training to the Health service providers Demand generation interventions on ASRH Programe Bimala Pandey

136. 1.Establishment of AFICs in schools 2.Menstrual Hygiene Management (MHM) 3Comprehensive Sexuality education (CSE) in schools Bimala Pandey

137. Problem of elderly women Reproductive Health Morbidity means any health condition adversely impacting the reproductive system as a result of reproduction, pregnancy, abortion, labor and sexual behaviour , and also refers to pelvic organ prolapse, obstetric fistula, infertility, cervical cancer, breast cancer as well as any other similar health conditions that affects the reproductive functioning. Cervical cancer, breast cancer, obstetric fistula, pelvic organ prolapses, and infertility are among the prioritized RH morbidities.

138. The worlds population s not only growing larger, it is ageing : virtually every country in the world is experiencing growth in the number and proportion of older population in the world. population ageing is an inevitable consequence of fertility decline, improvement in quality of life, availability of health care services ,decrease in mortality and increase in life expectancy. Bimala Pandey

139. The worlds population s not only growing larger, it is ageing : virtually every country in the world is experiencing growth in the number and proportion of older population in the world. population ageing is an inevitable consequence of fertility decline, improvement in quality of life, availability of health care services ,decrease in mortality and increase in life expectancy. Bimala Pandey

140. Major disease of elderly women Due to physiological and psychological changes during the older age, there are higher chances of suffering from different diseases. Here are some description of major diseases of elderly women. CANCERS: Osteoporosis Cardiovascular disease Vaginal prolapse Bimala Pandey

141. Bimala Pandey

142. Cont… Cancer: Due to exposure of estrogen and progestin, whether produced by a women's body or taken therapeutically , elderly women can suffer from reproductive tissue cancers(breast ovary, endometrium , vulva and cervix). Among them , two most frequent postmenopausal women suffer from breast cancer and cervical cancer. Bimala Pandey

143. Cont… Bimala Pandey

144. Violence against women

145. Violence against women any act of gender based violence that result in, or is likely to result physical, sexual or psychological harm or suffering to women including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life (CEDAW, 1993). The Convention on the Elimination of All Forms of Discrimination against Women ( CEDAW ), Violate and impairs or nullifies enjoyment by women of rights and fundamental freedom . Serious cause of death and incapacity E.g. incest, domestic violence, and rape, forced prostitution, sexual abuse, sexual harassment and trafficking.

146. Violence against women cont… VAW was acknowledged as a public health concern in 1996 Many including pregnant women and young girls are subjected to severe, sustained or repeated attacks 66% of Nepali women have endured verbal abuse, while 77% of the perpetrators were family members. 50% of women victims did not seek medical care.

147. Violence within the family Includes acts of physical aggression, like slapping, hitting, kicking and beating; psychological abuse, like coercion, ridicule and humiliating; and various controlling behaviors. Woman is more likely to be injured, raped, and killed by current or former partner than by any other person.

148. Causes of violence A/c to Heise (1998) Personal history factor (individual): Childhood experience of witnessing marital violence Being abused oneself as a child Absent or rejecting father Microsystems factor (family): Male dominance in family Male control of wealth in the family Use of alcohol Marital conflict

149. Causes of violence cont…….. Ecosystem factor (community): Women’s inability to access and control over power and resource, and their social support system Low socio-economic status Unemployment Isolation of women and family. Delinquent peer association.

150. Causes of violence cont…….. Macrosystem factor (society): Male entitlement/ownership of women. Masculinity linked to aggression and dominance. Rigid gender roles. Acceptance of interpersonal violence. Acceptance of physical harassment.

151. Factors influencing VAW in Nepal Economic dependency Lack of awareness Son preferences Effect of patriarchal upbringing. Fear of their children’s future Social pressure and prestige Police and related authorities.

152. Types of VAW in Nepal Psychological violence: Mental torture Emotional blackmail Verbal abuse Sexual harassment in public place. Sexual harassment in work place Sexual harassment in educational institutions.

153. Types of VAW in Nepal cont….. Physical violence: Assault and battery Rape Sexual abuse Enforced prostitution e.g. girls trafficking Kidnapping Medical violence such as sex selection during pregnancy and induced abortion.

154. Violence in the form of traditional practice Deuki, Badi Polygamy Jari Dowry related violence Bonded labor Child marriage Accusation of witchcraft Kumari (controversial)

155. National Reproductive Health Strategy

156. National Reproductive Health Strategy Implement the Integrated Reproductive Health Package at all levels based on standardized clinical protocols and operational guidelines. Enhance functional integration of RH activities carried out by different divisions. Emphasize advocacy for the concept of RH including inter and intra-sectoral collaboration.

157. National Reproductive Health Strategy Review and develop IEC materials Review and update the existing training curricula of various health workers. Ensure effective management system by strengthening and revitalizing existing committees at various levels.

158. National Reproductive Health Strategy Develop national RH research strategies which outlines research priorities and work plans based on information requirements of policy makers, planners, managers, and service providers. Construct /upgrade appropriate service delivery and training facilities at the National, regional, District and health post level.

159. National Reproductive Health Strategy Institutional strengthening through structural planning, monitoring/ Supervision and performance evaluation review. Develop an appropriate RH programme for adolescents. Support for national experts/consultants. Promote inter-sectoral and multi-sectoral co-ordination.

160. THANK YOU !!!