Reproductive Health

1. ReproductiveHealth

2. Health A state of complete physical, social, and mental well being and not merely the absence of disease or infirmity (WHO) Health is a resource for every day life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities

3. Wellness - a dynamic, growing process includes self responsibility, daily decisions, good nutrition, stress management preventive care and emotional health • Illness - a highly personal state, in which persons physical, emotional, intellectual, social development or spiritual functioning is diminished • Disease - an alteration in body function resulting in a reduction of capacity or shortening of normal life span

4. International Conference on Population and Development 1994 • UN brought 180 nations together at Cairo for a 20-year program of action to arrive at: • - Promotion of Human Development • - Stabilized Population Growth • - Improve Human Health, Education and Rights.

5. Reproductive Health Definition People have the ability to • Reproduce • Regulate their fertility • Safely go through pregnancy and childbirth • Get a successful pregnancy outcome (infant and child survival and well-being) • Enjoy safe sex

6. Reproductive Rights Couples are free and responsible to: • decide about the number and spacing of their children, with all information and means to do so • attain the highest standard of sexual and reproductive health • make decisions free of discrimination, coercion or violence

7. Reproductive Health PackageDeveloped for Pakistan in 1999 by multiple stakeholders • Comprehensive Family Planning • Pre - post- and natal care & Infant care • Adolescent Care • Prevention and treatment of infertility and abortion • Treatment of STIs/RTIs/HIV • Prevention and treatment of cancers • Management of menopausal/elderly problems • Management of RH issues related to men • Active discouragement of harmful practices (domestic violence; gender inequity)

8. R H – Life Cycle Approach

9. Why Sexual & Reproductive Health • Over 350 million people around the world lack access to comprehensive information and services pertaining to pregnancy, contraception and child birth • 75 million unwanted pregnancies annually • Every day 1600 women die from complications of pregnancies and child birth • Complications related to pregnancies is the number one cause of death for women aged 15-19 • Over a million are effected every day with STI’s

10. RH indicators in Pakistan • MMR 300-600 per 100,000 live births • IMR : 94 per 1000 live births • CPR: 31% • TFR: 3.1% • ANC coverage 28% • Attended delivery 34% • HIV/AIDS prevalence 0.1%

11. RH indicators in Pakistan • 500,000 Mothers are dying over the globe yearly • 25-30,000 Mothers are dying in Pakistan each year • One mother is missing after every 20 min. in Pak. • Mortality in F-children is 66 to 100% high in 1-4 and 5-9 year age groups • Maternal causes are one of the leading causes of mortality & morbidity in female poipulation.

12. Social determinants • Age at marriage • Age of child bearing • Child spacing • Family size • Fertility patterns • Education • Economic status • Customs & beliefs • Womens’ role in income generation

13. Behavioral Determinants • Norms • Knowledge • Attitudes • Beliefs • Skills • Self-efficacy Danger Signs LBW Special Care Special Care BD BD Postpartum Care for Newborn & Mother Antenatal Care Labor & Delivery Care Immediate Newborn Care BD BD BD BD Birth Asphyxia Danger Signs Special Care Special Care BD BD

14. ADOLESCENCE • The World Health Organization defines adolescence as the period between 10 and 19 years of age • Adolescents comprise almost 1/5th of the world's population • There are more than 1 billion young people ages 10 to 19 • In Pakistan, 1/4th of the population comprises of adolescents

15. Adolescent RH: Why a Special Concern? • Special reproductive health risks • Socio-cultural barriers to access to health care • Less informed, less experienced and less comfortable in accessing RH services • In conflict as need independent action, decision-making and emotional separation from their parents, while at the same time still feeling dependent on their parents for emotional, physical and financial support

16. ADOLESCENT ISSUES • Physical Changes • Psychological Changes • Social Changes

17. Physical Changes • Adolescents may feel worried and embarrassed about body changes, growth of hair, acne • feel self conscious about their body and how they look • Girls may become very sensitive and emotional just before menstruation

18. Psychological Changes • They often feel awkward, shy and confused • Changes in mood - feeling high or low- without reason • Strong need for acceptance leads to giving more importance to their peers than their parents • Feelings of anger, confusion and depression

19. Social Changes • Fond of going out with friends than staying at home • Tend to engage in risky and dangerous behavior • Attracted towards the opposite sex • Curious to learn what place sexual expression has in relationships

20. Onset of Sexual Activity • Beginning exposure to sexual activity • Exposure to health risks • STD and HIV infection • Early childbearing • Coincidence with timing of marital union • Cultural norms • Gender differences

21. Adolescents Health Risks • Early and unintended pregnancy: 40% of women give birth before age 20 in developing world • Unsafe abortions: up to 4.4 million abortions each year among adolescents • Increased risk of STDs: 60% of all new infections occur among 15 to 24 year olds • Harmful traditional health practices: 2 million girls undergo female genital cutting each year

22. Other Health Risk Factors • Smoking • Alcohol and drug use • Physical abuse • Mental health (depression) • Infection • Malaria • STD and HIV

23. Adolescent Reproductive Health: Programmatic Challenges • Adolescent sexuality: A sensitive subject in all cultures • A hard to reach group • Health care providers’ bias against adolescents

24. Recommendations • Programs should target parents in order to improve communication with young people regarding health issues (esp. girls) • Schools/ teachers can play an important role in imparting RH knowledge • Community programs should target peer group networks to reach boys • Life skills training essential to deal with later RH problems • Young husbands and wives should receive counseling on delaying first birth

25. Infections STI’s Infections communicated by sexual contact and through exchange of body fluids RTI’s All infections of the reproductive tract including those not cause by sexual contact

26. Infections - a Pubic Health Concern? • 40 million people are infected with HIV/AIDS. • 18 million people are living with HIV/AIDS • 7.3 million are women • 4.5 million are men • 340 million people infected each year with curable STIs • Nearly 1 million new cases occur each day • Responsible for greatest number of healthy years lost, after maternal causes, among women of reproductive age group in developing countries (excluding HIV/AIDS)

27. STIs and Reproductive Health • Estimated annual number of new cases • Syphilis 6.5 million • Gonorrhea 31.5 million • Chlamydia 47.0 million • Trichomoniasis 80.0 million • >50% of STIs in women are asymptomatic • Diagnosis is difficult • Access to STI services is poor; quality of services also poor.

28. Major Consequences of STIs Pregnancy Complications • Infants • Stillbirth • Low birth weight • Conjunctivitis • Pneumonia • Neonatal sepsis • Congenital abnormalities • Women • Preterm delivery • Premature rupture of membranes • Puerperal sepsis • Postpartum infection

29. PREVENTION • AWARENESS & BEHAVIOR CHANGE • SAFER SEX • ELIMINATING STIGMA • GENDER EQUITY

30. AWARENESS & BEHAVIOR CHANGE • COMFORT • ENHANCE SELF-ESTEEM • COMPLETE/CORRECT AGE APPROPRIATE INFORMATION • POSITIVE BODY IMAGE • NON JUDGMENTAL ATTITUDE • RESPECT • LANGUAGE

31. Impact of HIV/AIDS on Health • Direct effect: through AIDS deaths • Reversal of past gains in child survival • Decline in life expectancy • Indirect effects • Strains on the health system • Facilitation of spread of other diseases, e.g., tuberculosis

32. Trends in Pregnancy & Delivery • A large proportion of home deliveries (82%) • Contraceptive Prevalence Rate is 34% • Unmet need for FP is 33%

33. Safe Motherhood Challenges • Essential obstetric services • Quality routine antenatal and delivery care • Emergency services • Avoidance of unintended pregnancies • Safe abortion or post-abortion care • Delivery of post-abortion and post-partum family planning

34. Abortion • Approximately 25 million legal abortions annually (1 in 6 births) • Much higher if unreported illegal abortions included • About 20 million unsafe (1 in 7 births)

35. Total Number of Induced Abortions (Annual)

36. Total Number of Women Hospitalized for Complications of Abortion (Annual)

37. Contraception • Natural Method • Barrier contraception • Oral Contraceptives • Injectable contraceptives • Hormonal Implants • Skin Patches • Uterine Devices • Surgery

38. Breast Cancer • Incidence is lower in developing countries than developed • Rising trends --- • Risk factors include • early menarche • late menopause • late child bearing • short duration of breast feeding • HRT • radiations

39. Cancers of uterus Endometrial cancers • Most common malignancy in western population. • 6% of all incident cancers • Steady fall in death rate • Rare before 40, rapid increase after 44 years

40. Ovarian cancers • Common in developed countries • 4th most common cancer in women • Poor survival – • 6% of cancer deaths • Rare before 35 • 5 year survival only 30%

41. MENOPAUSE 13

42. Sexuality among older women. • Decreased libido…..?? • Illness and medications (especially antihypertensive agents, antipsychotics, and antidepressants) • impaired self-image

43. IMPACT OF AGING ON WOMEN • Age discrimination • Gender discrimination • Low social status ---step into old age with poor health • Rejection by children • Over burdened by the role as family care giver

44. Health needs of older women • From birth spacing to prevention child bearing • Menopausal Symptoms • New long term health risks • Osteoporosis • Cardiovascular disorders • Mental health problem • Reproductive health disorders including malignancies

45. Designing Health Services for Old Age • Diet, exercise and other healthy life style • Treatment of genitourinary tract infections, genital prolapse and fistulae. • Services and treatment for cancer • Counseling and treatment of menopausal symptoms. • Medical management of risk factors. • Out reach activities (Support group services and volunteer health promoters)

46. Gender-based Violence and Reproductive Health Herrera/Mexfam

47. Types of Violence Sexual M. Ramos/ReproSalud/Herrera Physical Psychological Psychological

48. Reducing Violence • Gender-based violence is a major public health problem • Violence directly affects women’s reproductive health

49. Effect of Violence on Women’s SRH • Involuntary sexual activity • Unintended/unwanted pregnancy • Unsafe abortion • Reduced ability to negotiate condom use • STI/HIV transmission • High-risk pregnancies and maternal deaths • Covert contraceptive use • Depression and low self-esteem

50. Psychosocial Risk Factors in Violence against Women • Witnessing marital violence as a child • Being abused as a child • Absent/rejecting father • Alcohol/drug use Mexfam