Global Health Challenges Social Analysis 76: Lecture 11

1. Global Health ChallengesSocial Analysis 76: Lecture 11 Harvard University Initiative for Global Health

2. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Harvard University Initiative for Global Health

3. Sexual and Reproductive Health Definitions • Consequences of sex in adults – STDs, maternal causes, HIV, Hepatitis B, Human Papilloma Virus • Consequences of sex in adults and children – adding congenital anomalies, birth asphyxia, birth trauma, and other conditions arising during the perinatal period. • Conditions of the reproductive organ systems – STDS, maternal causes, reproductive cancers • Conditions managed through reproductive health services – all maternal and child causes. • Conditions arising in the reproductive age-groups (15-44). • Health problems predominantly affecting reproductive age-groups. Harvard University Initiative for Global Health

4. Harvard University Initiative for Global Health

5. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Harvard University Initiative for Global Health

6. Population Explosion and Control Early 1960s, growing concern in high-income countries that population growth in developing countries would lead to a total world population beyond the earth’s environmental carrying capacity. During 1970s and 1980s, major investments by US and other Western donors in the development of contraceptive technologies and the delivery of contraceptive services to developing countries. Spectacular fertility declines in many countries beyond what was expected due to income growth or increases in educational attainment. Harvard University Initiative for Global Health

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8. Cairo Conference 1994 At the decennial International Population and Development Conference in Cairo in 1994, the population community favoured a major policy shift from a focus on population control to the delivery of reproductive health services including options for fertility regulation. One interpretation is that the population community was ‘captured’ by the health community. Harvard University Initiative for Global Health

9. Cairo Agenda • Eight target areas were identified: • Unplanned pregnancy and unsafe abortion • Maternal mortality and morbidity • Reproductive tract infections including STDs • HIV/AIDS • Reproductive tract cancers • Female genital mutilation and gender based violence • Infertility • Menopause Harvard University Initiative for Global Health

10. 10 Years After Cairo Huge decline in policy attention in population control – driven by declines in TFR and Cairo agenda change Reproductive health as an international political agenda has lost some of its prominence because of US and conservative states (Iran, Vatican) antagonism to components of the agenda. Reproductive health was not included as a specific goal in the Millennium Development Goals although reducing maternal mortality was one of eight goals. 2004 many reflections and analyses in the literature. Harvard University Initiative for Global Health

11. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Challenges and Controversies Harvard University Initiative for Global Health

12. Maternal Mortality • Three measures of maternal mortality: • Maternal mortality ratio – number of maternal deaths per 100,000 live births • Maternal mortality rate – number of maternal deaths per 100,000 women aged 15-49 • Lifetime risk of maternal death – cumulative probability of death from a maternal cause between 15 and 50. Harvard University Initiative for Global Health

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14. Maternal Causes • Haemorrhage – prepartum, intrapartum and postpartum • Sepsis – systemic infection • Hypertensive disorders or pregnancy – pre-eclampsia, eclampsia • Obstructed labour • Unsafe abortion • Other Harvard University Initiative for Global Health

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16. Low Birth Weight Approximately two-thirds of perinatal conditions are due to low birth weight, defined as a birth weight less than 2500 grams. Two causes of low birth weight: small for gestational age and preterm. In developing countries, largest component (60%) of low birth weight is small for gestational age. Risk factors include maternal nutritional status, diabetes, hypertension, malaria, anaemia …. A preterm birth is any birth prior to 37 weeks gestation (40 is normal). The earlier the birth the higher the probability of being born less than 2500 gms. Harvard University Initiative for Global Health

17. Birth Asphyxia and Birth Trauma Birth asphyxia is caused by a lack of oxygen to the fetus for long enough to cause permanent damage or death. Birth trauma is due to damage to the fetus during delivery. Birth asphyxia and birth trauma are strongly influenced by obstetric care during labour and delivery. Harvard University Initiative for Global Health

18. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Harvard University Initiative for Global Health

19. Contraception and Family Planning Fertility regulation through the provision of effective contraceptive technologies is an important intervention to reduce maternal mortality. Lifetime risk of maternal death is a function of the risk per birth and the total number of births. Countries with very high MMR also have high TFRs so that fertility reduction in these communities would have a significant impact on global maternal deaths. Effective contraception will reduce the abortion rate and maternal deaths associated with unsafe abortion. Reductions in the TFR will most likely lead to reductions in child mortality because of increased birth spacing. Harvard University Initiative for Global Health

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21. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Harvard University Initiative for Global Health

22. Antenatal Care Antenatal care came into widespread use in the UK in the 1930s as a means to identify women at risk of pre-eclampsia and eclampsia. In developing countries, antenatal care was promoted and has become one of the most widespread health interventions. The utility of risk assessment to reduce maternal mortality, the original basis for antenatal care has been questioned. Antenatal contacts can, however, be the basis for delivering a number of proven technologies. Even though, this potential is not yet used in many settings. Harvard University Initiative for Global Health

23. Antenatal Care Technologies • Intermittent prophylaxis for malaria • Nevirapine to reduce MTCT of HIV – new drugs being tested. • Treatment of STDs • Anaemia treatment • Pre-eclampsia screening through blood pressure measurement and detection of protein in a urine test • Education to identify dangerous complications during labour • Education to use insecticide treated nets Harvard University Initiative for Global Health

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25. Has the Investment in Antenatal Care Been Wasted? Enormous energy and resources have been invested in low-income countries to convince pregnant women to seek antenatal care and to make antenatal clinics physically, financially and culturally accessible. Antenatal care as delivered in most poor countries probably has a very limited effect on perinatal mortality and little direct effect on maternal mortality. At present, the major effect may be to increase the probability that a women’s birth is attended by a skilled personnel. The causality of this relationship, however, has not been established. Harvard University Initiative for Global Health

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27. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Harvard University Initiative for Global Health

28. Managing Labour and Delivery • Reducing maternal mortality requires: • Skilled birth attendants • Rapid referral and transport to emergency obstetric services when needed • Well-equipped and staffed health facility to undertake caesarian section, etc. Harvard University Initiative for Global Health

29. Roles of the Skilled Birth Attendant • Ensures a clean, safe, normal delivery • Recognizes and responds to complications by managing minor ones (removal of placenta, repair of vaginal tear, oxytocin for haemorrhage) and refers promptly major ones • Provides pain relief • Monitors maternal and fetal well-being throughout • Ensures newborn breathes on its own and is protected from hypothermia and cord infection • Ensures initiation of early breastfeeding Harvard University Initiative for Global Health

30. Essential Emergency Obstetrical Care • Capacity to carry out surgery – caesarian section, treatment of sepsis, removal of ectopic pregnancy • Intravenous oxytocin • Anaesthesia • Medical management of shock, sepsis, anaemia and hypertensive disorders of pregnancy • Replacement of blood • Manual procedures e.g. vacuum extractions • ……. Harvard University Initiative for Global Health

31. Skilled Birth Attendance Household survey data provide information on extent of skilled birth attendance, but not on the quality of the care. No real data on emergency obstetrical services. Skilled attendants is taken as a proxy for the package of services. But this indicator is probably much higher than percentage of women covered by the package of skilled birth attendance and emergency obstetrical care. Very complex intervention requiring physical, financial and cultural access to quality health care network. Harvard University Initiative for Global Health

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34. Definitions of Sexual and Reproductive Health Reproductive Health as Political Movement Burden of Reproductive Health Problems Contraception and Fertility Control Antenatal Care Labour, Delivery and the Post-Partum Period Abortion and Post-Abortion Services Harvard University Initiative for Global Health

35. Abortion and Post Abortion Care Approximately 70,000 women die each year from complications of abortion. Access to safe abortion would likely decrease maternal mortality from abortion. Post abortion care is also important and is composed of emergency services for complications of abortion, and post abortion family planning counselling. Because abortion is illegal or unpopular in many countries, the research on abortion and interventions to reduce its impact has been limited. Harvard University Initiative for Global Health