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Reproductive Health

Why address reproductive health?
Some Benefits of reproductive health interventions
Costs of reproductive health care
How to improve reproductive health
Do's and Don'ts
Resources
Useful websites

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Logo:  WHO - Reproductive Health


Why address reproductive health?

Reproductive health (RH) is a state of complete physical, mental and social well-being and not merely the absence of disease, in all matters relating to the reproductive system. RH implies that people are able to have a satisfying and safe sex life and that they have the capability and freedom to decide their reproductive choices. RH problems such as early and unwanted childbearing, HIV and other sexually transmitted infections, and pregnancy-related illness and death account for a significant part of the burden of disease among adolescents and adults in developing countries. The 1993 World Development Report showed that at least 13% of all DALYs were caused by RH problems. For women the proportion was 33%. RH problems are particularly concentrated among the poor who often lack access to minimal RH care. An estimated 120 million women wish to space and limit childbearing but lack access to family planning. Prevention is the most cost-effective approach to addressing most RH problems. Serious problems are costly and very difficult to solve once manifest. The adverse consequences of poor RH, and the benefits of good RH, extend well beyond health, and have an impact at the societal level. For example, early childbearing can have negative health and social consequences for young mothers and lasting effects on their children. Good RH increases productivity and well-being.

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Some benefits of reproductive health interventions

  • Improving adolescent reproductive health reduces unwanted pregancies and the risk of contracting HIV and other sexually transmitted infections. It improves the chances of girls continuing in school and expands their life options.
  • Providing life coping skills including RH education for boys and girls.
  • Prevention and management of sexually transmitted infections (STIs)prevents sexual spread of HIV.
  • Integrating HIV prevention activities in mother and child health (MCH) and family planning (FP) programs addresses missed opportunities to curb the HIV epidemic.
  • Being able to choose when to get pregnant, apart from being a health issue, greatly influences population growth, and environmental conditions.
  • Increasing contraceptive choices and access leads to fewer unsafe abortions – arguably the most easily avoidable cause of maternal death.
  • Life-saving care for complications from abortion is an excellent opportunity to provide contraception, avoiding another unwanted pregnancy.
  • Reducing pregancy-related deaths and illness in mothers increases newborn and child survival, and improves productivity.
  • Reducing maternal deaths depends on a functioning health system. Strengthening the system to improve maternal health brings benefits in many other areas of health.
  • Reducing violence against women decreases maternal and child morbidity and mortality, and unwanted pregnancy, and affirms the value of women in society

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Cost of reproductive health care

RH care is cost-effective - US$0.90/capita for family planning, US$3/capita for antenatal and delivery care, and US$0.20/capita for STD care - could avert an estimated 8% of the total global burden of disease (GBD). In addition, investing US$1.70/capita in HIV/AIDS prevention could avert an additional 2% of the GBD.

Reproductive Health - MDG Image

The main interventions to improve reproductive health can be grouped:

  • reduce unplanned and poorly timed pregnancies
  • improve prenatal and delivery care, including care of obstetric emergencies
  • increase the number of skilled providers
  • reduce the risk of STIs, including HIV/AIDS
  • reduce harmful practices and violence against women
  • address contextual factors: poverty, women’s education and status, lack of male involvement, and needs of adolescents

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How to improve reproductive health

1. Reduce unplanned and poorly timed pregnancies and the health risks associated with them. Include an appropriate array of high quality, consumer-oriented family planning information and services in benefits/service packages offered by public and private providers, and extend these services to hard-to-reach groups (youths, poor rural and urban people) through outreach and social marketing programs.

For women who resort to abortion to end an unwanted pregnancy, it is important that abortion services are safe and also that post-abortion services are provided, including guidance on contraceptive methods to avoid further unwanted pregnancies. Training and re-training of providers are also needed to maintain high technical quality of service provision, along with training on effective approaches to counseling and attention to client needs.

2. Reduce maternal mortality and morbidity by improving prenatal and delivery care and by ensuring effective management of obstetric emergencies. The World Health Organization has developed clear practice guides on maternal care that can reduce the health risks of pregnancy, delivery and the post partum period. Prenatal care and treatment for anemia, high blood pressure/edema and other complications are very cost effective.

Ensuring that every delivery is attended by a trained midwife or qualified health worker is a key intervention to reduce maternal death and illness. Obstetric emergencies can occur with any delivery, so attendants need to know how to recognize and respond to trouble signs. Referral to facilities that can manage complications such as hemorrhage, obstructed labor and sepsis, is also required. Referral centers need to be staffed with trained providers who are available at all times and equipped with adequate operating facilities, safe blood supplies and medicines. Transport and communication are also required, and families and communities need to be motivated to take action to save the life of a mother (and her child) when an emergency occurs.

3.Plan to increase the number of skilled providers. Since much of RH care – and especially professionalization of birthing care – depends on skilled care providers, long-term strategic human resource planning cannot be emphasized enough.

4. Reduce the risks of STI and HIV Infections. Unsafe sex increases the risk of contracting reproductive-tract infections and HIV/AIDS. The risk of HIV infection increases for women and men with lesions associated with other reproductive tract infections. Management and treatment of STIs can substantially reduce that risk. Use of condoms ad reducing the number of sexual partners are effective preventive measures that can be supported through targeted interventions for high risk groups, health education, promotion and community mobilization. Screening and counseling for those who are infected are also effective.

5. Address harmful practices. Female genital mutilation (FGM) is associated with complications of pregnancy and delivery and with sexual dysfunction. Because the practice is culturally ingrained, measures to reduce it need to work at several levels and engage the community, practitioners and policymakers. Domestic violence also contributes to poor reproductive health outcomes. Providers need to be trained to recognize the signs of violence, to use appropriate approaches to treatment and counseling, and to involve communities.

6.  Address factors beyond health care that affect reproductive health outcomes. Contextual factors, including poverty, malnutrition and the low status of women, as well as attitudes and behaviors of individuals, the community and providers can positively or negatively influence RH outcomes. The design of interventions needs to take account of forces outside the formal health system. Many of those who are at risk, youth as well as men, do not use clinical services provided through the health system and require special outreach initiatives. Countries need to look beyond the health system to deal with HIV/AIDS and problems such as poverty reduction, and gender equality.

 

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ObjectiveCore Interventions  Beneficiaries  Indicators 
1.  Reduce health risks of unwanted pregnancies
Reduce unplanned and poorly-timed pregnanciesExpand family planning services through community-based workers, social marketing and health facilitiesMen and women of reproductive health
  • Total fertility rate
  • Contraceptive prevalence rate
  • Unmet need for spacing and limiting births (DHS data)
  • Age at first birth
Reduce the risk of unsafe abortionEnsure safety of abortion where not against the law and provide post-abortion care and family planning information and servicesPregnant women, especially adolescents
  • % of gynecological admissions that are for abortion-related complications
  • Case fatality rate for post-abortion complications
2.  Reduce health risks of pregnancy and delivery
Reduce delays in recognizing and managing complications of pregnancy and deliveryEnsure prompt detection, management, and referral of complications.
Train staff in midwifery skills at all levels of the health system.
Pregnant women and their infants
  • Maternal mortality ratio
  • % of deliveries with skilled attendant
  • Maternal and perinatal death reviews
  • % of low-birthweight babhies
Improve the capacity of the health system to give quality maternal-newborn careEnsure early antenatal contact for care, counseling, and birth planning.
Improve quality of ANC, delivery, postpartum & newborn care through competency-based training and supervision.  Stress life-saving skills
Pregnant women and their infants
  • % of pregnant women receiving antenatal care at least once
  • % of pregnant women who are anemic
  • Number and distribution of basic and comprehensive essential obstetric care facilities/500,000 pop.
Remove barriers that keep poor women from access to maternity carePromote community financing programs.  Promote private services for those who can afford it and assure public funds are used to finance transportation and care for the poor.Poor women
  • % of poor women who deliver with skilled attendant
3.  Reduce STI and HIV Infections
Reduce high-risk behaviors, particularly amond youth and other high risk groupsEducate men, women and youth about family planning and safe sex, and promote condoms that can be obtained through a variety of channels and behavior change communication.  Provide services for men and promote male involvementMen and women, particularly youth 
  • Age at sexual debut;  prevalence of casual sexual encounters without protection
  • Prevalence of condom use
  • Prevalence of STIs 
Reduce incidence/prevalence of RTIs/STIs, including HIV/AIDSEnsure availability of services for RTIs/STIs and treatment for other health conditions.
Provide appropriate laboratory equipment and drugs
Men and women of reproductive age
  • Case detection, treatment and cure rates 
4.  Reduce the prevalence of harmful practices that undermine women's health
Reduce prevlanence of FGMWork with community groups to find alternative rituals for initiation and/or alternative employment for individuals who perform FGM. 

Adolescent women

  • % of women reporting that they have undergone FGM
Reduce violence against womenImprove education of men and women about laws and educate aboue effects of violence on women and society.  Support involvement of women's groups.All women 
  • Incidence of rape
  • Violent death rate among women
5.  Reduce health risks of unwanted pregnancies
Create an enabling environment for improvements in reproductive health outcomesImprove education and nutrition for girls.  Provide credit and better employment opportunities for women.  Improve health communications capacity.  Support involvement of women's groups and men in reproductive health and rights.  Implement poverty reduction strategies.Women, particularly adolescents
  • Female secondary school gross enrollment rates
  • Stunting among girls 

 


Do's and Don'ts

DO pay attention to demand and access. Investments in health education and communication can increase utilization but have limited effect on demand for RH care. Improvements in women’s status through education and economic opportunity have a strong influence on demand for RH services, including family planning and delivery care.

DO pay attention to client perspectives and quality. Programs that pay attention to consumers work better than those that impose top-down targets and serve the needs of providers rather than consumers. Incentives that promote positive provider attitudes and behavior are more effective than targets and punitive management practices.

DON’T assume that improved performance has to cost a lot. Many countries have achieved better RH outcomes by using their existing resources more effectively by building strong political and grassroots support for improved RH outcomes. Improving the quality of family planning care is a good example of this.

DON’T neglect behavior change. This is required for individuals, families, communities and providers if RH outcomes are to improve. Effective health promotion and communications have contributed to better RH outcomes by reducing risky practices (unprotected sex), promoting positive ones (better hygiene and nutrition), and making providers more attentive to the needs of their clients.

DO plan for the long term to reduce maternal mortality. Long-term efforts are required to improve capacity for management of obstetric emergencies and to professionalize birthing care.

DO involve adolescents in RH programs both on the information side (in schools and to out-of- school youth) and in the provision of youth friendly RH services.

DON’T neglect cervical cancer prevention.Programs can work in poor country settings, but need careful planning to be feasible and effective.

DO aim to reduce violence against women. This is one example of putting women’s rights in focus, and an effective way of mobilizing society’s resources to improve RH outcomes.

DO invest in women's reproductive health early in the life cycle. By treating protein-energy and iron/folate deficiency in adolescents, young women will better tolerate the increased demands of pregnancy, birth and lactation. The chances for a normal birth, resulting in normal birth weight and optimal growth and development of the baby are strengthened.

DO encourage male involvement for better promotion of responsible sexuality. Men and women need equal access to information, education and services.

DON’T neglect the disadvantaged and hard to reach groups. An effective way to serve the needs of high risk groups and the poor is to involve community groups and NGOs.

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Resources

World Bank, 1999, Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis,Washington, D.C.

World Bank, 1999, Population and the World Bank: Adapting to Change,Washington, D.C.

World Bank, 1999, Safe Motherhood and the World Bank: Lessons from 10 Years of Experience,Washington, D.C.

World Bank, 2000, Improving Women’s Health: Issues and Interventions,Washington, D.C.

World Bank, 2000, Contracting-out for Reprodutive Health: A Guide,Washington, D.C. (Also available in French and Spanish)

World Bank, 2001, Condom Procurement Guide,Washington, D.C.

Bulletin of the World Health Organization,Volume 79 No 3 2001, Estimates of maternal mortality for 1995. Kenneth Hill, Carla AbouZahr, & Tessa Wardlaw.

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Useful Websites

http://www.unfpa.org/
http://www.who.int/reproductive-health/index.htm
http://www.safemotherhood.org/
http://www.unaids.org/
http://www.rho.org/

For further information contact Sadia Chowdhury in the World Bank HNP Anchor (schowdhury3@worldbank.org), Khama Rogo in the World Bank Africa Region (krogo@worldbank.org).

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