Reproductive Health
Content of the lecture
• Reproductive Health Definition and Indicators
• Components of Reproductive Health
• Maternal Health
• Family Planning
• Sexually Transmitted Infections
• Abortion
• Violence Against Women
Definition of Reproductive health
Reproductive health is defined as” A state of
complete physical, mental, and social well being
and not merely the absence of disease or
infirmity, in all matters related to the
reproductive system and to its functions and
process”.
Components of Reproductive Health
[Link] family planning services
2. Promoting safe motherhood: prenatal, safe
delivery and post natal care, including breast
feeding
3. Prevention and treatment of infertility
4. Prevention and management of complications of
unsafe abortion
[Link] abortion services
[Link] of reproductive tract infections
including sexually transmitted infections;
Components of reproductive health
7. Information and counseling on human sexuality,
responsible parenthood and sexual and
reproductive health
8. Active discouragement of harmful practices, such
as female genital mutilation and violence related
to sexuality and reproduction
Reproductive Health indicators
1. Total Fertility Rate: Total number of children
a woman would have by the end of her
reproductive period, if she experienced the
currently prevailing age-specific fertility rates
throughout her childbearing life. TFR is one of
the most widely used fertility measures to
assess the impact of family planning
programmes.
Reproductive Health indicators
[Link] Prevalence (any method):
Percentage of women of reproductive age who
are using (or whose partner is using) a
contraceptive method at a particular point in
time.
Reproductive Health indicators
3. Maternal Mortality Ratio: The number of
maternal deaths per 100 000 live births from
causes associated with pregnancy and child
birth.
4. Antenatal Care Coverage: Percentage of
women attended, at least once during
pregnancy, by skilled health personnel for
reasons relating to pregnancy.
Reproductive Health indicators
5. Births Attended by Skilled Health Personnel:
Percentage of births attended by skilled health
personnel. This doesn’t include births attended
by traditional birth attendants.
6. Availability of Basic Essential Obstetric Care:
Number of facilities with functioning basic
essential obstetric care per 500 000 population.
Essential obstetric care includes, Parenteral
antibiotics, Parenteral oxytocic drugs, Parenteral
sedatives for eclampsia, Manual removal of
placenta, Manual removal of retained products,
Assisted vaginal delivery. These services can be
given at a health center level.
Reproductive Health indicators
7. Availability of Comprehensive Essential
obstetric care: Number of facilities with
functioning comprehensive essential obstetric
care per 500 000 population. It incorporates
obstetric surgery, anesthesia and blood
transfusion facilities.
8. Perinatal Mortality Rate: Number of Perinatal
Deaths (deaths occurring during late pregnancy,
during childbirth and up to seven completed days
of life) per 1000 total births. Deaths which occur
starting from the stage of viability till completion
of the first week after birth (22 weeks of gestation
up to end of first week after birth, WHO). Total birth means live birth
plus IUFD born after fetus
reached stage of viability.
Reproductive Health indicators
9. Low birth Weight Prevalence: Percentage of
live births that weigh less than 2500 g.
10. Positive Syphilis Serology Prevalence in
Pregnant Women: Percentage of pregnant
women (15–24) attending antenatal clinics,
whose blood has been screened for syphilis,
with positive serology for syphilis.
Reproductive Health indicators
11. Prevalence of Anemia in Women: Percentage
of women of reproductive age (15–49) screened
for haemoglobin levels with levels below 110 g/l
for pregnant women and below 120 g/l for nonpregnant
women.
12. Percentage of Obstetric and Gynaecological
Admissions Owing to Abortion: Percentage of
all cases admitted to service delivery points
providing in-patient obstetric and gynaecological
services, which are due to abortion (spontaneous
and induced, but excluding planned termination
of pregnancy)
Reproductive Health indicators
[Link] Prevalence of Women with FGM:
Percentage of women interviewed in acommunity
survey, reporting to have undergone
FGM.
14. Prevalence of Infertility in Women:
Percentage of women of reproductive age (15–
49) at risk of pregnancy (not pregnant, sexually
active, noncontraception and non-lactating) who
report trying for a pregnancy for two years or
more
Reproductive Health indicators
15. Reported Incidence of Urethritis in Men:
Percentage of men (15–49) interviewed in a
community survey, reporting at least one episode
of urethritis in the last 12 months.
16. HIV Prevalence in Pregnant Women:
Percentage of pregnant women (15–24)
attending antenatal clinics, whose blood has
been screened for HIV, who are sero-positive for
HIV.
Reproductive Health indicators
[Link] of HIV-Related Prevention
Practices: The percentage of all respondents
who correctly identify all three major ways of
Reproductive Health preventing the sexual
transmission of HIV and who reject three major
misconceptions about HIV transmission or
prevention
Maternal Health
Motherhood should be a time of expectation and joy for
a woman, her family, and her community. For women in
developing countries, however, the reality of
motherhood is often grim. For those women,
motherhood is often marred by unforeseen
complications of pregnancy and childbirth. Some die in
the prime period of their lives and in great distress: from
hemorrhage, convulsions, obstructed labor, or severe
infection after delivery or unsafe abortion.
Safe Motherhood
The strategies adopted to make motherhood
safe vary among countries and include:
1. Providing family planning services.
2. Providing post abortion care.
3. Promoting antenatal care.
4. Ensuring skilled assistance during childbirth
5. Improving essential obstetric care.
6. Addressing the reproductive health needs of
adolescents.
Essential Services for Safe Motherhood
Safe motherhood can be achieved by providing
high quality maternal health services to all
women. These services for safe motherhood
should be readily available through a network of
linked community health care providers, clinics
and hospitals. These services could be provided
at different levels including home and health
institutions.
Essential Services include:
1. Community education on safe motherhood
2. Prenatal care and counseling, including the
promotion of maternal nutrition
3. Skilled assistance during childbirth
4. Care for obstetric complications, including
emergencies
5. Postpartum care
Essential Services include:
6. Post-abortion care and, where abortion is not
against the law, safe services for the termination
of pregnancy
7. Family planning counseling, information and
services
8. Reproductive health education and services
for
adolescents
Maternal Mortality
Definition : maternal death as the death of a
woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the
duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy
or its management, but not from accidental or
incidental causes.
Maternal Morbidity
Definition : Any deviation, subjective or
objective, from a state of physiological or
psychological well being of women.
Causes of Maternal Mortality and
Morbidity
[Link] Obstetric Deaths : are those that result
from
obstetric complications of the pregnancy state
from interventions, omissions, incorrect
treatment or from chain of events.
Examples: Abortion, Ectopic pregnancy, pre-
eclampsia, Eclampsia, Obstructed labor,
infection, etc.
Causes of Maternal Mortality and
Morbidity
Commonest Direct Obstetric Cause:
A. Hemorrhage: Includes antepartum,
postpartum, abortion, and ectopic pregnancy.
B. Unsafe Abortion: It is claimed as the
commonest cause of maternal death in our
country accounting for 20 –40% of deaths.
C. Hypertensive disorders of pregnancy: This
includes pre-eclampsia, eclampsia, etc.
Preclampsia and eclampsia account for 10-
12% of maternal deaths.
Causes of Maternal Mortality and
Morbidity
Commonest Direct Obstetric Cause:
D. Obstructed Labor and uterine rupture: The
prevalence of obstructed labor is said to be 47
% in Ethiopia. It accounts for 9% of the total
maternal death.
E. Infection: The introduction and multiplication
of microbial agents in the pelvic organs and
other systems having an effect on the health of
the mother and newborn. It includes infection
of the uterus, tubes, urinary system and fetal
infection. It accounts for 10% of maternal
deaths.
Causes of Maternal Mortality and Morbidity
Indirect Obstetric Death: Deaths resulting from
previous existing diseases or diseases that
developed during pregnancy
A. Anemia: This is the commonest indirect cause
of maternal death in our country, since
malaria is endemic and iron supplementation
is low
B. Other indirect causes include, heart disease,
diabetes mellitus, HIV/AIDS, TB, Malnutrition,
etc. The indirect obstetric death:
Maternal Mortality in Context: The Three
D’s (Delays)
• 1. Delay in deciding to seek care
• Failure to recognize signs of complications
• Failure to perceive severity of illness
• Cost consideration
• Previous negative experience with the health
• system
• Transportation
Maternal Mortality in Context: The Three
D’s (Delays)
2. Delay in reaching care
• Lengthy distance to a facility
• Conditions of roads
• Lack of available transportation
Maternal Mortality in Context: The Three D’s (Delays)
• 3. Delay in receiving appropriate care
• Uncaring attitudes of providers
• Shortages of supplies and basic
• equipment
• Non-availability of health personnel
• Poor skills of health providers
Causes of Maternal Morbidity
Maternal morbidity is difficult to measure due to
variation in the definition and criteria to
diagnose. The risk factors for maternal morbidity
include prolonged labor, hemorrhage, infection,
preclampsia, etc.
Factors affecting women health
[Link]-cultural factors: Like early marriage,
early childbirth, harmful traditional practices
including female genital mutilation, etc.
Factors affecting women health
2. Economy: Socio economic status affects the
women’s status by affecting their decision
making roles in the community, educational
status, health coverage, level of sexual abuse,
etc.
Factors affecting women health
3. Inadequate Health Service Coverage: Most
mothers do not get care during pregnancy and
most deliveries are unattended. This is due to
lack of transportation, distance from health
facilities, small number of health facilities, etc
Factors affecting women health
4. Psychological factors: For instance, after sexual
abuse women are at great risk of depression.
[Link] and nutrition services: The health status of
women who are not getting adequate amount of
nutrients and proper reproductive health services
could be affected.
Factors affecting women health
6. Interaction with providers: Some health care
providers are, unsympathetic and uncaring as they
do not respect women's cultural preferences. E.g.
privacy, birth position, or treatment by women
providers.
[Link] Discrimination: E.g. lack of women
empowerment, giving more attention to a male child.
Family planning
• Definition:
Family Planning involves planning the number,
frequency and timing of pregnancy. In other
words it is a program to regulate the number
and spacing of children in a family through the
practice of contraception or other methods of
birth control
Benefits of family planning to women’s health
1. Avoiding pregnancy at the extremes of
maternal age
2. Decreasing risks by decreasing parity: If all
women had five births or fewer, the number of
maternal deaths could drop by 26 %
worldwide.
3. Preventing high-risk pregnancies: decrease
maternal deaths by quarter
4. Prevention of unwanted pregnancy: reduces
unnecessary risks of pregnancy, childbirth and
risks of induced abortion
5. Improving health through non-contraceptive
benefits including prevention of STIs and
reproductive cancers
Types of Family Planning
Types of Family Planning
[Link] contraceptive methods :
include oral contraceptives pills, injectables, and
implants. They all prevent pregnancy mainly by
stopping a woman’s ovaries from releasing eggs.
Hormonal methods contain either one or two
female sex hormones that are similar to the
hormones naturally produced by a woman’s
body.
Types of Family Planning
[Link] contraceptive pills:
should be taken one pill every day. They are
most effective when no pills are missed, the pill
is taken at the same time every day,and each
new pack of pills is started without a delay.
Types of Family Planning
[Link] contraceptives:
are given by injection into a woman’s arm or
buttocks once every 1, 2, or 3 months,
depending on the type of injectable. Injectables
are most effective when women remember to
come back for re-injection on time.
There are 3 different varieties of Injectable Contraceptives available
1. Monthly Injectable – Cyclofem/ Cycloprovera
and Mesigyna/ Norigynon.
[Link]-monthly Injectable – Noristerat and
Norethindrone Enanthate – NET-EN
3. Quarterly Injectable – DMPA (Depo medroxy
progesterone acetate)
Types of Family Planning
[Link] implants:
are inserted under the skin of a woman’s upper
arm and provide continuous, highly effective
pregnancy protection for 3 to 5 years,
depending on the type of implant. When this
time is
over, new implants can be inserted during the
same visit that the old set is removed.
Contraceptive Implants
Types of Family Planning
[Link] contraceptive pills (ECPs):
can help prevent pregnancy if taken within 5
days after unprotected sex. The sooner they are
taken, the more effective they are. They are NOT
meant to be used for ongoing contraception, in
place of a regular method.
Emergency contraceptive pills
Pills can be taken after unplanned, unprotected
coitus as emergency contraceptive after
consulting the doctor . A dose of 4 tablets of a
low dose pill within 72 hours of un protected
intercourse followed by 4 more tablets 12 hours
later.
Types of Family Planning
[Link] contraceptive devices (IUDs or IUCDs):
are small, flexible plastic devices that are inserted
into the woman’s uterus. The most common IUDs
contain copper, and they work by preventing sperm
from reaching an egg. Depending on the type, IUDs
can provide protection for 5 to 12 years
Intrauterine contraceptive devices (IUDs or
IUCDs):
Types of Family Planning
[Link] methods are either devices (male and
female condoms):
that physically block sperm from reaching
an egg, or chemicals (spermicides) that kill or
damage the sperm in the vagina. The
effectiveness of barrier methods greatly
depends on people’s ability to use them
correctly every time they have sex.
Types of Family Planning
[Link] awareness methods:
require a couple to know the fertile days of the
woman’s menstrual cycle — the
days when pregnancy is most likely to occur.
During these fertile days the couple must avoid
sex or use abarrier method to prevent
pregnancy.
Fertility awareness methods
Types of Family Planning
[Link] provides contraceptive:
protection for the first 6 months after delivery if
certain conditions are met. This approach is
called the Lactational Amenorrhea Method or
LAM.
Types of Family Planning
11. Female and male sterilization:
are permanent methods of contraception.
Sterilization involves a relatively simple surgical
procedure that provides life-long protection
against pregnancy. Sterilization is appropriate for
men and women who are certain they do not
want more children.
Types of Family Planning
[Link]:
involves a man withdrawing his penis
during sex and releasing his ejaculate, which
contains sperm, outside the woman’s vagina. For
most people withdrawal is one of the least
effective contraceptive methods.
Sexually Transmitted Infections
Reproductive tract infections (RTIs) are
infections of the genital tract of women and
men
Types of STIs
1. Sexually transmitted infections (STIs)
Infections caused by organisms that are
passed through sexual activity with an infected
partner. More than 40 have been identified,
including Chlamydia, gonorrhea, hepatitis B and
C, herpes, HPV, syphilis, trichomoniasis, and HIV.
Types of STIs
2. Endogenous infections
– Infections that result from an overgrowth of
organisms normally present in the vagina.
– These infections are not usually sexually
transmitted, and include bacterial vaginosis and
candidiasis.
Types of STIs
3. Iatrogenic infections
– Infections introduced into the reproductive tract
by a medical procedure such as menstrual
regulation, induced abortion, IUD insertion, or
childbirth.
– This can happen if surgical instruments used in
the procedure are not properly sterilized, or if an
infection already present in the lower
reproductive tract is pushed through the cervix
into the upper reproductive tract.
Main STI Pathogens
More than 30 pathogens are transmissible through
sexual intercourse-oral, anal, or vaginal. The main
sexually transmitted bacteria are:
1. Neisseria gonorrhoeae (causes gonorrhoea)
2. Chlamydia trachomatis (chlamydial infections)
3. Treponema pallidum (causes syphilis)
4. Haemophilus ducreyi (causes chancroid)
Main sexually transmitted viruses
Human immunodeficiency virus (causes
AIDS)
1. Herpes simplex virus (causes genital herpes)
2. Human papilloma virus (causes genitalwarts).
3. Hepatitis B virus
4. Cytomegalovirus
Main parasitic organisms
Trichomonas vaginalis (causes vaginal
trichomoniasis)
Classification of STIs
1. Diseases characterized by genital ulcer
• Chancroid, Genital herpes simplex virus,
Granuloma inguinale (Donovanosis),
Lymphogranuloma Venarum, Syphilis
Classification of STIs
2. Diseases characterized by urethritis and
cervicitis
• Chlamydial infection, Gonorrhea
Classification of STIs
3. Diseases characterized by vaginal discharge
• Bacterial vaginosis, trichomoniasis,
Vulvovaginal candidiasis
Classification of STIs
4. Pelvic Inflammatory Disease (PID)
5. Epididymitis
6. Human papilomavirus infection (Genital wart)
7. Vaccine preventable STDs
• Hepatitis A, Hepatitis B
8. Proctitis, Proctocolitis and enteritis
9. Ectoparasitic Infections
• Pediculosis Pubis, Scabies
Main STI syndromes
1. Genital ulcer
2. Inguinal bubo
3. Scrotal swelling
4. Vaginal discharge
5. Lower abdominal pain
6. Neonatal conjunctivitis
STI Control Strategies
1. Prevention by promoting safer sexual behaviors
2. General access to quality condoms at affordable
prices
3. Promotion of early recourse to health services by
people suffering from STIs and by their partners
4. Inclusion of STI treatment in basic health services
5. Specific services for populations with frequent or
unplanned high-risk sexual behaviors
STI Control Strategies
6. Proper treatment of STIs, i.e. use of correct and
effective medicines; treatment of sexual partners;
education and advice; reliable supply of condoms;
7. Screening of clinically asymptomatic patients;
8. Provision for counseling and voluntary testing for
HIV infection;
9. Prevention and care of congenital syphilis and
neonatal conjunctivitis;
10. Involvement community, in prevention
of STIs and prompt contact with health services for
those requiring care.
ABORTION
Abortion is the termination or initiation of
termination of pregnancy before reaching
viability (before 20weeks or <500grams
according to WHO.
WHO characterizes unsafe abortion by the lack
of skilled providers, safe techniques, and/or
sanitary facilities.
Introduction
• It could be induced or spontaneous.
• Three consecutive abortions would be
termed; habitual abortion.
• The frequency of spontaneous abortions is
12 to 15%.
• The frequency of habitual abortion is about
0.4 to 0.8%.
• 75% of spontaneous abortions occur
before the 16th week of gestation and 62%
before 12 weeks.
Abortion-related morbidities and
mortalities
Unsafe abortion is a global problem. Millions of
women around the world risk their lives and
health to end an unwanted pregnancy. Every
day, 55, 000 unsafe abortions take place–95 % of
them in developing countries-and lead to the
deaths of more than 200 women daily. Globally,
one unsafe abortion takes place for every seven
births.
Acute Complications of unsafe abortion
1. Incomplete abortion
2. Sepsis
3. Hemorrhage
4. Uterine Perforation
5. Bowel injury
Long term Complications of unsafe abortion
1. Chronic pelvic pain
2. Pelvic inflammatory disease
3. Tubal blockage and secondary infertility
4. Ectopic pregnancy
5. Increased risk of spontaneous abortion or
premature delivery in subsequent
pregnancies.
Types of abortion
PREVENTION of Abortion
• Progesterone: R M Oates Cochrane, 14
trials, 1988 women; progestogens and
placebo with similar outcome.
• Bed rest: A Aleman (2005) 2 studies of 84
women, placebo and bed rest similar,
hospital and home bed rest similar, HCG
reduced miscarriage more than bed rest.
Treatment of Threatened abortion
• The most frequent indication of cerclage is
prophylaxis, around the 15th week of
gestation; Mac Donald (1963) and
Shirodkar (1955).
post-abortion care
1. Treatment of incomplete and unsafe abortion
2. Counseling
3. Family planning services
4. Links to comprehensive reproductive health
services and Community
5. Service provider partnerships.
Violence Against Women
Globally, at least one in three women has experienced
some form of gender-based abuse during her lifetime.
Violence against women is any act of gender-based
violence that results in, or is likely to result in,
physical,
sexual, psychological harm or suffering to women,
including threats of such acts, coercion or arbitrary
deprivations of liberty, whether occurring in public or
private life. A
Violence Against Women
Women with a history of physical or sexual
abuse are also at increased risk for unintended
pregnancy, sexually transmitted infections, and
adverse pregnancy outcomes. Females of all
ages are victims of violence, in part because of
their limited social and economic power
compared with men.
Impact of violence on Health
[Link]: injuries, bruises, chronic pain
syndromes, disability, fractures, GI disorders,
irritable bowel syndrome, reduced physical
functioning
[Link] and reproductive health: gynecological
disorders, infertility, PID, pregnancy
complications/miscarriage, sexual dysfunction,
STIs including HIV/AIDS, unsafe abortion and
unwanted pregnancy
Impact of violence on health
[Link] and behavioral: alcohol and
drug abuse, depression and anxiety, poor
selfesteem, psychosomatic disorders, unsafe
sexual
[Link], phobias and panic disorder
Fatal health consequences: AIDS-related
mortality, maternal mortality, homicide, and
suicide
Supporting Women Who Disclose Abuse
1. Assess for immediate danger
2. Provide appropriate care
3. Document women’s condition
4. Develop a safety plan
5. Inform women of their rights
6. Refer women to community resources
7. Community health promotion
8. Communication campaigns
Prevention strategies also need to focus on
1. Empowering women and raising their
status
2. Combating norms of violence
3. Reducing poverty and alcohol consumption
References
• Reproductive health for health science students. university of
[Link] at
[Link]
cture_notes/health_science_students/RH_HSS_final.pdf
• A guide to family planning for community health workers and their
clients. WHO available at
[Link]
• Facts for family planning :family planning methods.ch7. available at
[Link]
• WHO. Prevention and Control of STIs: draft global strategy. May 2006
• WHO. Sexually transmitted and other
reproductive tract infections. 2005
• WHO. Training modules for the syndromic management of STIs. 2nd
edition
• [Link]
g/link/5591420408ae15962d8d4f2f/download