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The need for a reproductive health approach
A,
&men3
that tie foundations of he& ore Iaid in childhood and adolescence, mtd we btfluenced by factors such as nwition, education. sexual roles and social status, cultural practices, and the socioeconomic environment. Reproductive health care strategies to meet women’s multiple needs include education fc+- respotw%le and healthy sema~ity~ safe and qpro2ric?e co!!tmce.ption, and servicesfor sexually trammitted diseaw, pregnenSy, delivery, and abortion.
Keywords: Abortion; Reproductive Policy: Sex education: Adolescents.
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Intmdocticn Reproductive health is inextricably bound up with reproductive rights and freedoms. This bnaoltant fact was recognized by Christopher Tie&, who devoted much of his life to establishing the impact on women of various patterns of fertility and fertility control behavior. His work pro?ided insights for social oolicv chances of inestimable benefit to
originators of the modem, broad and comp&r&e concept of reproductive health. Reprodwtive health can be defined as the abiiii’ “f men and women to undtiake sexual activity saic!y, whether or not pregnancy is desired and, if it ia desire !, for the woman to carry the pregnancy to twm safely, deliver a hcaltby infant and be prepared to i.-r!we it. Reproductive health is affected by the ecur.omic, social. cultural, and educational environment in which girls are born, grow to womanhood, marry, and repeat the process in stating their own fami!ies. In the last decade, and particu,arIy in the last 5 years, health prcicssiooals have begun to move from a veg narrow concept of maternal health to a mere inclusive concept t&t recognizes the role of much more fundamental issues, such as women’s rights and status in society, the physical and intellectual hwniliations that are woman’s lot in many societies, .md ik wert and covert violence rr.,%edout to wumen. All these conditions substantially influewe women’s sexual development, their health, and their patterns of childbearing.
A broad reproductive health appproxh is preferable to a maternal health approach for several import.ant rearms. First, it is very *iff&It to define-i-here matcmal health :egins. In dealing with maternal health problems, one should recognize that health problems in early childhood and adolescence contribute to conditions that may interfere with safe
sexuality, pregnancy and delivery in Ir.ter life. because the foundations of health are iaid during chudhood and adolescence, a reproductive health approach mcompasses nutrinon, development, education, and the socioeconomic environment girls and adolescent women experience. A reproductive health approach also recognizes that maternal mortality, currently the main indicator of women’s health, is just the tip of the iceberg of the problems caused by sexua!ity and pregnancy. The extent and nature of mob b,‘diti have yet to be systematicallv measured, but it has been estimated that, in developing countries, for every woman who ,iies in pregnancy another lo-15 suffer serious impairment $74). Many conditions are exacerbated by pregnancy. or are a greate- problem to pr&nant women. Morbidity resulting from “T exacerbated by pregnancy is thus an important element in reproductive health that needs much more attention. A reproductive heaah franzwork facilitates more comprehensive assessment of the reiative risks of childbearing and fertility contm!. It is necessary to look at all women of reproductive age, not jur+ pregnant women, in assessing the absolute nod relative risks of orennancv. abortion. and various methods of >o&aception. At p&sent our understanding of these risks is mostly d&d from studies ib Western countries. h;iany more Third World studies are needed, like the recent assessment of the relative risks of reproduction and iontraceptive use in Egypt and Icdonesir [::. Basic understanding and definition o: the different elements r&ted to reproductive risk for a particular woman at a particular time also nc~d considerable further work. Pixd1v. service provision could benefit from a -broader definition of reproductive he&h A narrow emphasis on women as mothers, reflected in the orovision of services through maternal and ihild health (MCH) and family planning channels, usually means that many women are not served, and that many reproductive health ytoblems go unre-
corded and untreated. MCH and family planning services do little to meet the reproductive health needs of male ard female adolescents, men, t:le unmarried, the infertile. those with sexually transmitted diseases, and, in many countries, those with unwanted pregnancies. The causes and extent of reproductive health problems Our ignorance of the causes and extent of reproductive health problems is abysmal. These include not just pregnancy-related morbidity and mortality, but also the psychological and emotional problems of teenagers and battered wives and the consequences of economic deprivalion and harmful cultural practices. All still wait to be studied. The roots of unregulated fertility and poor Paaltb care lie deea in socia! attitudes that value women maibly for having chi!dren. Both men and women are victims of low levels of socioeconomic development in most developing countries, but the situation of women is compounded by sexual disczimination starting at birth. The lives of women in many developing countries aptly fit the description of life in a State of Nature given by social philosopher Thomas Nob&s: “Nasty, brutish, and short” [141. In some societies, the preference for sons is leading to abuse of the technology of sex determination prior to birth and to abortion of female fetuses [ZS]. There have been reports of female infanticide in India (251, tbough such reports are difficult to verify tl71. Under age 5 mortalitv statistics do, however, show a grcawr toll on infant and young girls than on boys in several countries in Asia and the Middle East 1341. Less dramatic, but significant, discrimination is revealed in differential nutrition and health care of girls compared to boys. Although the nutritional requirements of young boys and girls are the same, in many societies, boys, and later males, are being fed firsi., and given better and more food. Studies in slorne countries have revealed that mothers
than girls and that medical care is more often sought for a sick boy than for a sick gir! ita;. Without adequate nutrition, girls’ growth is stunted a”d bones do not grow as they should. Cephalopelvic disp:oportion is a common consequence and results i” obstructsd labor. Low levels of education also constrain women’s ability to care for their own and tb:ii chiidren’s health [II]. In most of Ceotrf Africa, and the Arabic speakiw countries of North Africa, across the Middle East, and in the countries of India. Pakistan and Bangladesh, 75% of adult women are illiterate. In the majority of these countries, this rate is twice that amor& men. ‘l% discrepacy between men and women is much less in Latin America where fates of female illiteracy are rarely above 50% [351.
suckle boys longer
Gir:s join their mothers early in the tasks of home and field. In much of Africa. girls work
from as e&y as age 5 or 6 snd have little or no time foi ihemselves. Hard physical :abm and genelaly poor nutrition contribute :o poor physical development. Anemia has particularly severe consequences for women. Menstruation and. later, reproduction or use of a” IUD. increase the need For sever.11 dietary compoce”ts, principally iron and folic acid. Studies bv the Wor!d Health Orzanization (WHO) &ow that women of refioductive age require a daily absorption of iron approximately three times that of adult me”. But poor dieis azzd lack of access to dietary supplements result in very high prevalence of anemia among -women in developing countries. Anemia is often comuounded bv infection, especially parasitic dise&es such ai malaria ~“6 hookwcrm. Estimates bv WHO sta?e that 50% of all women and 75% bf preg“ant worn?” have hemoglobin lev+ below those defined by WHO as indica’ive of a~:mia 1321. Much of the cultural and social disc ;mi”ation meted out to girls and women stems from the belief in most societies that a ma” is SWierior to a woman, and that this superiority is best guamteed by denying the latter azy reproductive rights, freedoms, and choices.
The fact that sexual enjoyment need not lead to procreation is easily accepted for the m&e, bm no: FIX :hc fema!e. E”-r-. ..a ._, I.h !ricar. men, for example, oppose contraception for their wives because “thLT can the” be unfaithful without being caught.” Various practices aimed et controlling girls’ and women’s sexuality inciude iemak cixumcision. scarification, -dowry, and wife beating. ii; many societies, early marriage, eve” child marriage, lead to very early childbearing with all its attendant risks. Women are domina,ed by me” in o:her ways tbai give them li?aie or no room io control their lives. For exxzjle, in some cultures, womec ‘-sic no rizhts over the mooertv thev bring iK?cIthe m&a:: wd nb rights o&r their childrcu. Very little acknuaiedgment is give” to the economic contribution; that women make to the household and to 111~ country at large, eve” though, for example. women are responsible for zt !ca.it 50% of the world’s food productio” [35]. Sucn tasks: oerformed in addition to their domestic responsibilities, create greatly disproportionate burdens on girls and women. Much unnecessary suffering and ill health result from these various discrimin&ny beiiefs and practices. They are compmmdcd by ignorance and !ack of good health cae Women’s major reproductive health problems - maternai mortality, materne! morbidinfertility and scx11z!!y ity, abortion, transmitted diseases (STDsJ - are review-5 below. The actoil :evei of maternal mortality is pot ksown for most developing countries, in part brraose &is issue hes unti! mccmiy :sen ;.:glecteci. Out also because of basic data problem.:. inadrqr?ate vital including registration and lack (of reliable data on the deaths o! women of reproductive age and causes of death. lndependem studlea of maternal mortality, eve” in the United States, show that mate:“4 mortality as recorded in official statistics is underreported [2].
Draths from abortion are particularly underenumerated where induced abortion is ~c&. ?~kiixii mortality is estimated to be the first or second most important cause of death among women of reproductive age in Third World countries. It accc~~xs for 25% of their deaths [311. An estimated half a million women a year, 99% of them io the developing world, die of maternal crl~ses. On average, there are 500 maternal waths per 100,000 live births in developing countries; ratios of ovc: ! .OCtO per 100,006 have been recorded in some areas 1391. The level and pattern of fertility both affect the number of times women are exposed to risk, and the amount of risk. According to World Fertility Suwe$ data, women aged 40-49 in Kenya and Lesotho L--1 . ..^..I cn average, 19 and 15 years, II_ “y4x,r, respectively, in childbearing [40]. In Africa, where a woman bears, on average, 6 or I children, her Lifetime chance of dying from pregnancy-related causes is 1 in 21. At the other end of the spectrum, in Western Europe, whex a woman has two children with little obstetric risk, her !ifetime chance of dying is 1 in 10,000 1131.If cbi!dbearing statis very early or continues into older years, and if a woman has many closely-spaced births, she faces increased risk to ber health and life. it is estimated that the direct causes of maternal tnortahty - chiefly hemorrhage, infcciion, and toxemia - account for about 75% of maternal mor:ality 1131. Anemia is a serious underlying factor in maternal mortality. A recent study in Bangladesh, for example, concluded that anemia was a factor in nearly all of the maternal deaths ihat occuneri ihere [I], and ir recent workshop in Lusaka identified anemia as the most important complication of pregnancy in tropical Africa [Xl. Obstructed labor, often caused by cephalopelvic disproportion is an important killer. One observer has noted that if Western obstetric practices could be applied to women in Africa, 50% of all women would have elective cesarian section and 25% is&iy
would have acute cesarian section due to narror’neaa of the pelvis [IS]. The definition of a maternal death has changed over the years, reflecting a growing understanding that it is the ultimate event on a road from which there could have teen maw nossible avenues of escaue 151.Until 10 years igo, WHO classified a &a&al death as one that resulted directly from pregnancy or childbirth (known as a “direct” maternal death). The classification was later expanded to include “indirect” deaths - those resulting from pre-existing conditions exacerbated by rnegnancy or from illness contracted during pregnancy that carries an increased risk for the uregnaut woman. To these factors rnav be added the underlying causes, such as poor or harmful social, cultural, or cnvlronmental conditions, including the absence of adequate and accessible he&Ii care.
Many women snrvive pregnancy, chlldbirth or abortion without dvltnr. but with serious physicai impairmeuts or %fections that may lead to long-term health problcl-a, and frequently tc infertility. Evidence ir largely anecdotal, however. A study in India in the 1970s found that for every maternal death, there were 16.5 cases of ilIneas related to pregnancy. childbiih. and the ouerwrium 141. It has been reported xcently~:hal300 yo;& women a month are ?reated for repair of vesico-vaginal Iistulae in one gynecology clinic in Northern Nigeria, while in other areas the waiting list is said to be 1000 women [36]. The majority of wotucn so handicapped are cast out by their husbands, with no support and often turn to prostitution or die a slow, difficult death. In the same area of Nigeria, it has been estimated that for every woman whc, died as a result of childbirth, about 15 suffercd permanent handicap [ 111. Apart f;om chronic morbidity caused by pregnancy itself, pre-existing morbidity is often exacerbated by pregnancy or leads to sewc cwwequences that otherwise might not have occurrxi. For example, anemia can lead
to hemwrhagic complications in pregnancy. Most infectious illnesses are more common or more serious in pre8naxy. Malaria and infectious hepatitis are mo:c harmful for xcgnant women than for :he general population, and rhe effects of diabetes and cardiov,wular. kidney, and lung diseases are all exacerbated by pregnancy. Indicators of maternal morbidity have yet to be developed, and no systematicattempt at classification has yet been made. Classi.“.cations analogous to those used for matemd mortalitv miaht be artemoted - direct. indirect. and accidental mordidity. It would also be useful to distinauish between morbiditv in pregnancy cuiminiting in maternal mortality and morbidity resulting from pregnancy, delivery, and abortion, whether managed through adequate health care systems or not. Abortion
Pregnancy presents a great :isk when it is unwanted and abortion is legally restricted and carried out by untrained practitioners. It is, of course. difficult to obtain wzurate figures for the incidence of clandestine abortion, but Measham and Rochat [24] report that WHO studies in various settings indicate that it ~wmuts for 7-50% of maternal deaths, with a median of 15%. Althoueh it was .lgreed at the International Conf;?rence on Population in M&co City in 1984 that .;bortion was not to be generally considered a method of family planning, it is nevertheless definitely d method of fertility regulation that women have used from time immemorial, and to which thev will continue to turn. whatever the risks. It has been estimated that worldwide there are 30-40 million leaallv - induced abnnions every year. In addition, there are some W-20 mii’;on clandestine abortious every year. This trzxlates into an abortion rate of 37-55 abortions per It?00 women aged 15-W and au abortion ratio of 24-32 per lt?O pregnancies [IZ]. In other words, every year, between 3 and 6% of womeu of reproductive age undergo abortion, and 1 in 4 pregnancies
aze terminated in this way. These very high figures demonstrate a great need for sate, effective and acceptable contraception; for safe pregnancy termination services; and for organized and humane treatmem of abort& compticatians in all circumstausr~, MortaliQ in legal abortions is estimated to be 2 per 100,UOOprocedures in industrialized countries and 6 per 100,ooO in developin countries 119. But dandestine abortion gives rise to very high mortality - 50 deaths per 1OWOO prcced.ares in develcned countries and about 4(10deaths per 100 000 procedures in developing countries 2151.This last figure is probably a substantial underestimate of the dangers of clandestine abortion. Khan [IS] documents 10 deaths in 412 procedures, yielding a death to case rate of 2400 per lW,uU procedures. The most severe consequences of clandestine abortion often occur among poor and iliiterate women in commonities with restrictive abortion laws. 14 rmncb of Latin America, where abortion is banned Iexcept for medical reasons or in cases of rape, it is estimated that 1 in 3 women has had an abortion and that tip :; 50% of materaz? deaths are due to associated complication [HI. In Asia. about 20-23% of maternal deaths are atibutahle to ooorlv oerformed abortion 119.301. In Africa, hospital studies show that abortion-related deaths are increastig. More than 25% of maternal deaths in Lusaka, Zambia [29], and more than 20% in Benin City. Niaeria 1381are due to abortion complicat&~s. - A po&lation-based study conducted in Addis Ababa. Ethiooia. revealed that 50% of maternal mot&ii& resulted from illegal abortion [2!]. Many maintain, wrongly, that abortions are uncommon in Africa. Studies in Nairobi indicate tha; abortions were common in the late 1970s and early 198Os, wheu 24lOO---3ooO women a year were being admitted to Kenyatta Hospital for abortion compkations. Currently, they are treating over 10,GOOcases a year-a five-fold increase 131.A 1987 study in Nigeria showed that abortion is not only a problem of the young and unmarried.
Approximately 30% of septic abortirw were in women over 25 vears old: sour 35% of tho:- who had induced abo&ns were currently married; and about 52% had two or mora children 1271.A hosoiral studv in Ghana found that a&on; obst&ic patients with at least one previous pregnancy, over 20% reported having at least one induced abortion 1221. fioorly performed abortion causes mortalitv. sterilitv. and ill-health. Illenal abortions w&z WO&I~S lives and ruin the chances of their families, but praaching and punishment will not stop them. Given current technology, we need to ask whether permitting such carnage to continue is human or humane. Documentation of the consequences of legai restrictions on abortion is desperately needed as a basis for policy reform. Yet opposition to legal abortion has caused funding for abortion-lclated research to dry up. Any policy that hir;drrs understanding of such a common cause of human suffering and death must be ccwdcred unacceprable and must be fought vigorously. Infertility andSTDs
The problem of infertility is extremely serious in some parts of the world, particularly where the failure to have children can lead to divorce and ostracism. Surveys uave found that an average of 12% of women in subSairaran Africa were childless at the end of their chiidhearing years. although maternal mortality may have reduced the number of fecund women. This compares with a rate of 2-3% in other developing countries 171. Secondary infertility is also a major problem in many areas of Africa. More couples come to African clinics with secondary infertility than in any other part of the world. The two mobt important reasons for this high level of infertility are unhygienic obstetric and abortion procedures and the prevalence of sexually transmitted diseases (STDs), which are extensively reviewed in this issue by Wasserheit. In some areas of Africa. there are indications that 15-30% of young men and women aged 15-24 have contracted an STD
[IO]. The correlation between the prevalence of STDs and HIV infection, which in Africa is killing as many women as men, adds urgency to the calls to include morbidity arising from sexual activity among the problems addressed by reproductive health care programs and policies. Approaching o solution to reproductive health problems Reproductive health problems so deeply rooted in defects in the social, cultural, economic, legal, and political environments are not amenable to a short-term solution. They require a determined, long-term strategy encompassing all aspects of general, equitable development. Fortunately, some reproductive health issues can and do respond to specific actions. Countries and communities need to recognize the complementarity of long- and short-term strategies for solution and plan lhem accordinelv. Among tbe;ost basic long-term solutions will be education, particularly of girls; elimination of nutrition problems; improvement in general economic conditions; repeal of laws inimical to the development of women; elimination of social and cultural practices that discriminate against women and hold them in bondage to inen; and the creation of a political environment in which women are active participants in the evolution of national policies. While achievement of these long-term goals is sought, some relatively short-term developments can make a great deal of difference to the reproductius lives of women. These include .xassive health education campaigns tluouah schools. mass media. wom&‘I organizitions, and othe? chanhels to make citizens understand and use better the services available. Components of reproductive health programs and policies are reviewed below, including services for girls aged S-15 years, famil I) planning, maternity services, and abordon services. Servicesfor girls aged S-15 Girls (and boys) need to know how they
will develop, and the physical and emotional facts and requirements of sexual relationships before they face these events in their own lives. The information should be presented in different ways as the child erows. As well as being appropriate to the age of the child, the information must be culturally seositive. Health care providers working in existing programs - in primary health care, in maternal and child health, in family planning could perhaps team up with schoo!s to provide this information. Parents, teachers, and health care providers must also be made aware of the importance of adequate growth in young and adolescent girls, and of the dangers of deficiencies in diet or nutritional status (e.g. lack of iron, vitamin D. or iodine), which vary from locality to locality. In addition, young people entering their reproductive years~need~o khow the f&s, the’risks, and the kinds of service-s available to them if they are sexu;ll!y active, including family planning, STDs, infertility, otxr reproductive he&h con(izit!s, and mat mity. In areas where few children attend secondary schools, other agencies such as churches. youth groups, and women’s organizations must be encouraged to act. Parents need support and help in discussina these delicate details with their children. It isa parental respolsibitity to see that young people are not placed at risk through igno-
rance. If parents abrogate their resvonsibilitv in this matter, the knowledge may come fro&t harsh experience, or from other sources such as the media of other young people whose messages may well conflict with parental val“es. Peer pressure has an important influence on adolescent behavior, particularIy where changing levels of education are creating a communication gap between the generations. This force can sometimes be used to advantage. The decision whether or not to engage in sexuai activity is ;ULimportant one, and peer group counseling can help the young adolescent learn how to respond to peer pressure. Early female marriage does not avoid the problems related to adolescent fertility: rather, the issues become different. Parents
must roaiiz? that providir,: for girls incindes protecting them from the often considerable health risks of pregr,ancy and childbearing before they are fully grown. R&ions leaders, community !eaders, health w&kers and tsachers must all use their inflcence to discourage marriage before the age of et least 16. Familyplanning
Family planning services help individuals and couples to exercise reproductive choices. These programs should emphasize responsible parenthood and the roles and responsibilities of men, as fathers and as husbands. to USC contraceptives or support their wives’ use. Family &nnin~ . - services should inc!ude abor-
tion counseling where possible, and t;ezt~& of or referral for treatmeat of STDs. Similarly, services must be provided to deal with the problems of inferti!i:y. Family planning has the potential to decrease maternal deaths by reducing the number of pregnancies among women of hi& parity. among women in the age groups carrying most risk, and among women who would risk clandestine illegal abortion Zf faced with an unwanted pregnancy. The major contribution that family planning can make is by reducing fertility. It is estimated that a median of 24% of matomal deaths could be averted by contraceptive use among feexld women not currently using contraception but desiring no further births 1231.Recently, there has been actual evidence of family planning’s effects in this regard. In Matlab, BangIadesh, a clear and consistent differential has emerged between a treatment area with an extensive family planning program and a nearby comparison area. In the ninth year after the stut of the project, although with considerable fluctuation in between, the maternal mortality rate per 100,ooO women of reproductive age in the comparison area was twice the rate in the treatment area [ZOI. Whatever its other contributions, family planning is a right of individuals and couples. For women, it is basic to their ability to control their bodies and enjoy other r:ghts.
Family planning, essential fo: reproductive health, has so many henefits, lo so many people, that its provision should not he confined to MC9 services. MCB pro~atns do not in general reach men, whose participation in hmilv olanninz could make a real contribution ~o’improv&~ents in women’s reproduo. tive health. In addition, they do not reach the unmarried, particularly adolescents. To xhieve reproductive health, the widest possible contraceptive choices are necessarg. Restriction of choices for ideological or ~.ay nther rea~cmleads to poor use of contrace tion. Furthermore, women (and men) may find different methods moie suitable at different times. Given the safety and side-effects of c~rren!!y available methods, women especially need choices among methods. Research ou contraceptive safety is needed in every country to assess the posossibleeffects of particular methods on general health, nUtiand other physiological tional status, conditions specific to the local environment. For many women in the developing world, pregnancy and childbearing take place with little or no trained assistance. Of the 05% of the world’s births that take place in developing countries, less than 50% are attended by a physician, nurse, rnl&ife, or trained treditional birth attendant 1331. In many coontries, fewer than 5O”ioof mothers receive one or more antenatal consultations with a trained person [33]. It appears to be within the capacity of most Loontries to pro\-ide better reproductive health services if they want to. The recent conferences on Safe Motherhood and Better Health for Women and Children Through Family Planning agreed that primary health care (PHC) strateaies should be altered to have a Getter ‘impact on women’s needs. Community antenatal care is essential to ensure that every delivery is assisted by a trained health worker, to provide appropriate and accessible preventive routine care, to facilitate early referral of high risk cases, and to prowde alarm and transportation systems for complicated deiiveries.
Important reductions in mortality could be achieved simply by assuring that safe services are available and accessible to women who qualify for them under existing law. In India, where abortion is allowed on demand UDto 10 weeks of gestation and with medical yeview thereafter, only 1 in 6 abortions are provided by trained providers in safe conaitions 191. In Bangladesh, menstrual regulation services, recognized and supporied as a preventive health service. still reach only lO-20% of the three qua& of a miltion7women who are estonated to attempt to terminate pregnancy every year 191. In many countries, health workers either do not know the laws oc interpret them too narrowly. Teachers and trainers ,3f health care providers, as well as pmviders themselves, need to know the law and act to the full extent possibIe. In many countries, the laws need to be excmined in relation to the realities of women’s needs sod practices, and altered as needed. Where abortion remains restricted, the burden of responsibility lies with governments to ensure adequate access to sex education and contruxp?ion. Over the long term, history tells us that as contraceptive rates rise, abortion rates decline 181.
We bav
seY@ringthe linlx brtween sex and procreation, azd a!! artificial methods of fertility r@gU1ation, with the exception of periodic abstinence, are opposed. In other cases, it is felt that, because contraceptio:: frees sexual activity from the risk of pregnancy sod therefore remov@s the “moral sanction” presented by this risk, contraception will lead to moral laxity and promiscuity. Specific p+pu!ation subgroups may also be denied their right to make decisions about reproductive behavior; for example, parental or sp+x~sal consent might be required, or provision of services denied to adolescents 01 the unmarried. The debate is even more heated with regard to abortion. Where national laws permit, family piatming and other health professionals should be allowed to operate without external pressure from donor governments. Where abortioz are legally restricted, the handling and evmtual treatment o: patients is a human and medical problem. In no other condition is a patient made to feel so humiliated. It is a fact that well-off women who want an abortion badly enough succeed in obtaining it safely, even in the iace of the most stringent laws. The painful truth is that it is usually the poor and the uneducated who are exposed to the gxeatest risk, an example of further discrimination against the most vulcerable members of society. To improve reproductive health. pariicuMy for women, the Safe Motherhood Conference (held in Nairobi in 1987) made a number of recommendations. One highlighted the need to generate political commitment to reallocate :esources to use the knowledge and technol@gies available now. In addition, the conference’s “Call to Action” emphasized that better ha&h and nutrition with services for children ax needed particular attention to the needs of &Is, to ensure they reach their childbearing years in the best of he&h. Girls must dso be piaided with better access to education, which is a key to increasing control over one’s life and environment. Family planning and family life education programs must be expanded, particularly for
young people, and services for planning families must be made more socially, culturally, financially, and geographically accessible. These services must be prusidcd sacb that pregnant Women receive antenatal care, screening. and referral to w&l-equipped and well-staffed facilities and have access to an alarm and transport system in case of @m@[email protected] services must also enable women to avoid unwanted pregnancies or terminate unwanted pregnancies safely, and enable both men and women to rec@ive treatment and counseling for infertility and for SMJS. An integrated approach must be taken to reproductive health care, making it a priority within the context of primary health care. Decision-makers in government, commlmities, and families mu% be reached, so they may change laws and attitudes and improve the legal and health status of women generally, especially in areas such as adolescent marriage and restrictions on health-care delivery. Finally, the community must be mobilized, particularly the women themselves, to pian and implement policies, programs, and projects so their c&s and preferences are explicitly taken into accwnt. One of the statements issued by Third World women from 26 countries and their [email protected] 17 western countries at the 1985 UN Coi.ference on the Decade of Women stated that “women in the Third World denand access to all methods of family p!anning, including abortion as a back-up method, and assert our right to choose for ourselves what is best for us in our situation. By protecting our i&s, we protect the lives of those children that we genuinely want and can care for. TSis is our conception of ‘Pro-Life’ [9].” The rights for which these wome., ask received international silpport long ago. Article 14(t3 of the 1974 World Population Plan of ,-&on states that “alI couples and individuats have the basic right to decide freely and responsibly the number and spacing of their children, and to have the infommtion, education and means to do so....” A right is no right if those for whom it is meant
do not know of its existence, and if services are nor provided to ensure its enjoyment. It is ihe respons;hility of governments and organizations wwking ir. health to ensure that individuals and coudes are aiven access to both the facts and th; services~ In addition to this. s&eties she-uid make aJ! &fort to free their citizens of practices, taboos and consrrahxs which deny them other reproductive rights and freedoms. The most fundamental freedom in this respect comes with the ability to separate sex from reproduction. The benefits of the freedom to use contraceotion were vividly described by Dr. Elizabeth Connell, formerly Associate Professor of Obstetrics and Gvnecoloev at the Columbia Universitv
Medics Sck$, in evidence given before thk Nelson Committee February 24.1970 1371: “As a physician who began to practice before tht advent of the pill, I am constantly aware of the immense difference it has made to the lives of women, to their families, and to society as II whole. The look of horror on the face of a l&year-old giri shen you confirm her fears of pregnancy; the sound of a woman’s voice cursing her newborn and unwanted child as she lies on the delivery table; the absolutely helpless feeling that comes over you as you watch a ‘woman die following criminal abortion; the hideous responsibility of informing a husband and children that their wife and mother has just died in childbirth all these situations are deeply engraved in our memories, never to be forgotten. Since we have had more effective means of contraception, the recurrence of these nightmares has blessedly become less frequent. The thought that we may once again be forced to face these disasters on an increasing scale because of the panic induced by these hearings strikes horror into the hearts of all of us who have lived through this era once before.” Sadly, the gains described here a:e not uniformly available throughout the world. There are some 300 million couples, even today, who do not have access to cortraception. Study after study in many countries iq the
developing world show that the family planning needs of large pclwztages of marrisd women are still noi being met. What is even more disturbing is that &any young people are being comdetelv ianored. The statistics on induced abdrtio&, 0% unplanned pregnancies, and on the heart-rending problems of school dropout due to pregnancy are all warning signs ihat society is discriminating against some very needy persons. in maay developing countries today, the problem of induced abortion is growing, not only among the unmarried or the young, but across society. Where laws are restrictive, it is the poor and uneducated who are denied access to safe abortions. A responsive reproductive he&b cart strategy would attend to the reproductive health needs of all, by providing education for responsible and safe sex life, contraception for the sexually active to use as needed, and services for the management of pregnancy, delivery, and all abortions. It would also provide education and services for the a;evention and management of STDs, subfertd~ly, and iaf&ility. Its goal should be to mai.e lwman sexuality and reprodxtinn a joy - nc _Bcurse orapunishment.
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Oluko~a AA: Reananq rerndnarion: rexI% of a cornmunity-based shzdy in Lagos. Nigtia. Int J Gynecol Obstct>5S: 41. 19!3?. Pandya SK: Y zinzdmgfor baby boys. Br Med J 2%: 1312. ,918.
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Harrison K: Child-baring. health and social priorities: a wvw of 22.174 consecutive hospital births in Zaria, Northern Nigerin. Er I Obstct Gynaol91: 5,198S. Hmshaw SK: Induced abortion: a worldwide perrprcdue. I~l’amPlannPnrpccl 13: 12, ,987. Herr EL Mwhti A: The Safe Motherhood Initiative: Pmposals for Action. “Jashington, DC, The World Rank. 1981. HobbesT:~eLcviatha.MacMillan. NewYark,1651. Hogberg U: Malcrnal moflality - a world wide problem. Int 3 Gynecot Obrtci 2% 463. 1965. How& MM, Glass RI: Parental son prsfwnencc in seeking medical care For children less than fwe years of age in a rural community in Bangladesh. Am J Public Health 78: 1349.1988. Jeffrey P. Lyon *: Female infanticide. and amnioecnteas. SW M Mcd 19: 1207. ,984. Khan AR d 71: Indwicdab:oitior. iii I miid arca of Banglade&~. Stud :‘am PIpon 17: 95.1986. Khan AR n d: Maternal mortality in rural Ben&desh. World HealthForumS: 32S, 1985. Ktig MA et al: Maternal mortality in Matlab. Ban& de&. 19X-1985. Stud Fan Plann 19: 69. 1988. Kvast BlZ d al: Maternal mortality in Addis Ababa. Ethiopia. ShldFnm Platm IZ 288, 1986. Lam9::‘i P :t ak Abotion experience amm,,~ obrtctricpatimtr at KorlrBu Horpiul. Accra. Oh&m. J Bioscc Sci 17: iys. 1985. Maine D: Mcthtrs in peril: th: heavy toll of needlessdeaths. People 12:6,t985. Mcssham AR. Rocba, RW: Slowing the stork: better health for women through family &annin~. A backgound paper prepared for thy lntanationaJ Confcrmce
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World Hdlh orgnni7atiaa: Matcnd Tabulation of Available Informalion.
Mortality R&s 2nd edn. World
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that tie foundations of he& ore Iaid in childhood and adolescence, mtd we btfluenced by factors such as nwition, education. sexual roles and social status, cultural practices, and the socioeconomic environment. Reproductive health care strategies to meet women’s multiple needs include education fc+- respotw%le and healthy sema~ity~ safe and qpro2ric?e co!!tmce.ption, and servicesfor sexually trammitted diseaw, pregnenSy, delivery, and abortion.
Keywords: Abortion; Reproductive Policy: Sex education: Adolescents.
he&i-;
Intmdocticn Reproductive health is inextricably bound up with reproductive rights and freedoms. This bnaoltant fact was recognized by Christopher Tie&, who devoted much of his life to establishing the impact on women of various patterns of fertility and fertility control behavior. His work pro?ided insights for social oolicv chances of inestimable benefit to
originators of the modem, broad and comp&r&e concept of reproductive health. Reprodwtive health can be defined as the abiiii’ “f men and women to undtiake sexual activity saic!y, whether or not pregnancy is desired and, if it ia desire !, for the woman to carry the pregnancy to twm safely, deliver a hcaltby infant and be prepared to i.-r!we it. Reproductive health is affected by the ecur.omic, social. cultural, and educational environment in which girls are born, grow to womanhood, marry, and repeat the process in stating their own fami!ies. In the last decade, and particu,arIy in the last 5 years, health prcicssiooals have begun to move from a veg narrow concept of maternal health to a mere inclusive concept t&t recognizes the role of much more fundamental issues, such as women’s rights and status in society, the physical and intellectual hwniliations that are woman’s lot in many societies, .md ik wert and covert violence rr.,%edout to wumen. All these conditions substantially influewe women’s sexual development, their health, and their patterns of childbearing.
A broad reproductive health appproxh is preferable to a maternal health approach for several import.ant rearms. First, it is very *iff&It to define-i-here matcmal health :egins. In dealing with maternal health problems, one should recognize that health problems in early childhood and adolescence contribute to conditions that may interfere with safe
sexuality, pregnancy and delivery in Ir.ter life. because the foundations of health are iaid during chudhood and adolescence, a reproductive health approach mcompasses nutrinon, development, education, and the socioeconomic environment girls and adolescent women experience. A reproductive health approach also recognizes that maternal mortality, currently the main indicator of women’s health, is just the tip of the iceberg of the problems caused by sexua!ity and pregnancy. The extent and nature of mob b,‘diti have yet to be systematicallv measured, but it has been estimated that, in developing countries, for every woman who ,iies in pregnancy another lo-15 suffer serious impairment $74). Many conditions are exacerbated by pregnancy. or are a greate- problem to pr&nant women. Morbidity resulting from “T exacerbated by pregnancy is thus an important element in reproductive health that needs much more attention. A reproductive heaah franzwork facilitates more comprehensive assessment of the reiative risks of childbearing and fertility contm!. It is necessary to look at all women of reproductive age, not jur+ pregnant women, in assessing the absolute nod relative risks of orennancv. abortion. and various methods of >o&aception. At p&sent our understanding of these risks is mostly d&d from studies ib Western countries. h;iany more Third World studies are needed, like the recent assessment of the relative risks of reproduction and iontraceptive use in Egypt and Icdonesir [::. Basic understanding and definition o: the different elements r&ted to reproductive risk for a particular woman at a particular time also nc~d considerable further work. Pixd1v. service provision could benefit from a -broader definition of reproductive he&h A narrow emphasis on women as mothers, reflected in the orovision of services through maternal and ihild health (MCH) and family planning channels, usually means that many women are not served, and that many reproductive health ytoblems go unre-
corded and untreated. MCH and family planning services do little to meet the reproductive health needs of male ard female adolescents, men, t:le unmarried, the infertile. those with sexually transmitted diseases, and, in many countries, those with unwanted pregnancies. The causes and extent of reproductive health problems Our ignorance of the causes and extent of reproductive health problems is abysmal. These include not just pregnancy-related morbidity and mortality, but also the psychological and emotional problems of teenagers and battered wives and the consequences of economic deprivalion and harmful cultural practices. All still wait to be studied. The roots of unregulated fertility and poor Paaltb care lie deea in socia! attitudes that value women maibly for having chi!dren. Both men and women are victims of low levels of socioeconomic development in most developing countries, but the situation of women is compounded by sexual disczimination starting at birth. The lives of women in many developing countries aptly fit the description of life in a State of Nature given by social philosopher Thomas Nob&s: “Nasty, brutish, and short” [141. In some societies, the preference for sons is leading to abuse of the technology of sex determination prior to birth and to abortion of female fetuses [ZS]. There have been reports of female infanticide in India (251, tbough such reports are difficult to verify tl71. Under age 5 mortalitv statistics do, however, show a grcawr toll on infant and young girls than on boys in several countries in Asia and the Middle East 1341. Less dramatic, but significant, discrimination is revealed in differential nutrition and health care of girls compared to boys. Although the nutritional requirements of young boys and girls are the same, in many societies, boys, and later males, are being fed firsi., and given better and more food. Studies in slorne countries have revealed that mothers
than girls and that medical care is more often sought for a sick boy than for a sick gir! ita;. Without adequate nutrition, girls’ growth is stunted a”d bones do not grow as they should. Cephalopelvic disp:oportion is a common consequence and results i” obstructsd labor. Low levels of education also constrain women’s ability to care for their own and tb:ii chiidren’s health [II]. In most of Ceotrf Africa, and the Arabic speakiw countries of North Africa, across the Middle East, and in the countries of India. Pakistan and Bangladesh, 75% of adult women are illiterate. In the majority of these countries, this rate is twice that amor& men. ‘l% discrepacy between men and women is much less in Latin America where fates of female illiteracy are rarely above 50% [351.
suckle boys longer
Gir:s join their mothers early in the tasks of home and field. In much of Africa. girls work
from as e&y as age 5 or 6 snd have little or no time foi ihemselves. Hard physical :abm and genelaly poor nutrition contribute :o poor physical development. Anemia has particularly severe consequences for women. Menstruation and. later, reproduction or use of a” IUD. increase the need For sever.11 dietary compoce”ts, principally iron and folic acid. Studies bv the Wor!d Health Orzanization (WHO) &ow that women of refioductive age require a daily absorption of iron approximately three times that of adult me”. But poor dieis azzd lack of access to dietary supplements result in very high prevalence of anemia among -women in developing countries. Anemia is often comuounded bv infection, especially parasitic dise&es such ai malaria ~“6 hookwcrm. Estimates bv WHO sta?e that 50% of all women and 75% bf preg“ant worn?” have hemoglobin lev+ below those defined by WHO as indica’ive of a~:mia 1321. Much of the cultural and social disc ;mi”ation meted out to girls and women stems from the belief in most societies that a ma” is SWierior to a woman, and that this superiority is best guamteed by denying the latter azy reproductive rights, freedoms, and choices.
The fact that sexual enjoyment need not lead to procreation is easily accepted for the m&e, bm no: FIX :hc fema!e. E”-r-. ..a ._, I.h !ricar. men, for example, oppose contraception for their wives because “thLT can the” be unfaithful without being caught.” Various practices aimed et controlling girls’ and women’s sexuality inciude iemak cixumcision. scarification, -dowry, and wife beating. ii; many societies, early marriage, eve” child marriage, lead to very early childbearing with all its attendant risks. Women are domina,ed by me” in o:her ways tbai give them li?aie or no room io control their lives. For exxzjle, in some cultures, womec ‘-sic no rizhts over the mooertv thev bring iK?cIthe m&a:: wd nb rights o&r their childrcu. Very little acknuaiedgment is give” to the economic contribution; that women make to the household and to 111~ country at large, eve” though, for example. women are responsible for zt !ca.it 50% of the world’s food productio” [35]. Sucn tasks: oerformed in addition to their domestic responsibilities, create greatly disproportionate burdens on girls and women. Much unnecessary suffering and ill health result from these various discrimin&ny beiiefs and practices. They are compmmdcd by ignorance and !ack of good health cae Women’s major reproductive health problems - maternai mortality, materne! morbidinfertility and scx11z!!y ity, abortion, transmitted diseases (STDsJ - are review-5 below. The actoil :evei of maternal mortality is pot ksown for most developing countries, in part brraose &is issue hes unti! mccmiy :sen ;.:glecteci. Out also because of basic data problem.:. inadrqr?ate vital including registration and lack (of reliable data on the deaths o! women of reproductive age and causes of death. lndependem studlea of maternal mortality, eve” in the United States, show that mate:“4 mortality as recorded in official statistics is underreported [2].
Draths from abortion are particularly underenumerated where induced abortion is ~c&. ?~kiixii mortality is estimated to be the first or second most important cause of death among women of reproductive age in Third World countries. It accc~~xs for 25% of their deaths [311. An estimated half a million women a year, 99% of them io the developing world, die of maternal crl~ses. On average, there are 500 maternal waths per 100,000 live births in developing countries; ratios of ovc: ! .OCtO per 100,006 have been recorded in some areas 1391. The level and pattern of fertility both affect the number of times women are exposed to risk, and the amount of risk. According to World Fertility Suwe$ data, women aged 40-49 in Kenya and Lesotho L--1 . ..^..I cn average, 19 and 15 years, II_ “y4x,r, respectively, in childbearing [40]. In Africa, where a woman bears, on average, 6 or I children, her Lifetime chance of dying from pregnancy-related causes is 1 in 21. At the other end of the spectrum, in Western Europe, whex a woman has two children with little obstetric risk, her !ifetime chance of dying is 1 in 10,000 1131.If cbi!dbearing statis very early or continues into older years, and if a woman has many closely-spaced births, she faces increased risk to ber health and life. it is estimated that the direct causes of maternal tnortahty - chiefly hemorrhage, infcciion, and toxemia - account for about 75% of maternal mor:ality 1131. Anemia is a serious underlying factor in maternal mortality. A recent study in Bangladesh, for example, concluded that anemia was a factor in nearly all of the maternal deaths ihat occuneri ihere [I], and ir recent workshop in Lusaka identified anemia as the most important complication of pregnancy in tropical Africa [Xl. Obstructed labor, often caused by cephalopelvic disproportion is an important killer. One observer has noted that if Western obstetric practices could be applied to women in Africa, 50% of all women would have elective cesarian section and 25% is&iy
would have acute cesarian section due to narror’neaa of the pelvis [IS]. The definition of a maternal death has changed over the years, reflecting a growing understanding that it is the ultimate event on a road from which there could have teen maw nossible avenues of escaue 151.Until 10 years igo, WHO classified a &a&al death as one that resulted directly from pregnancy or childbirth (known as a “direct” maternal death). The classification was later expanded to include “indirect” deaths - those resulting from pre-existing conditions exacerbated by rnegnancy or from illness contracted during pregnancy that carries an increased risk for the uregnaut woman. To these factors rnav be added the underlying causes, such as poor or harmful social, cultural, or cnvlronmental conditions, including the absence of adequate and accessible he&Ii care.
Many women snrvive pregnancy, chlldbirth or abortion without dvltnr. but with serious physicai impairmeuts or %fections that may lead to long-term health problcl-a, and frequently tc infertility. Evidence ir largely anecdotal, however. A study in India in the 1970s found that for every maternal death, there were 16.5 cases of ilIneas related to pregnancy. childbiih. and the ouerwrium 141. It has been reported xcently~:hal300 yo;& women a month are ?reated for repair of vesico-vaginal Iistulae in one gynecology clinic in Northern Nigeria, while in other areas the waiting list is said to be 1000 women [36]. The majority of wotucn so handicapped are cast out by their husbands, with no support and often turn to prostitution or die a slow, difficult death. In the same area of Nigeria, it has been estimated that for every woman whc, died as a result of childbirth, about 15 suffercd permanent handicap [ 111. Apart f;om chronic morbidity caused by pregnancy itself, pre-existing morbidity is often exacerbated by pregnancy or leads to sewc cwwequences that otherwise might not have occurrxi. For example, anemia can lead
to hemwrhagic complications in pregnancy. Most infectious illnesses are more common or more serious in pre8naxy. Malaria and infectious hepatitis are mo:c harmful for xcgnant women than for :he general population, and rhe effects of diabetes and cardiov,wular. kidney, and lung diseases are all exacerbated by pregnancy. Indicators of maternal morbidity have yet to be developed, and no systematicattempt at classification has yet been made. Classi.“.cations analogous to those used for matemd mortalitv miaht be artemoted - direct. indirect. and accidental mordidity. It would also be useful to distinauish between morbiditv in pregnancy cuiminiting in maternal mortality and morbidity resulting from pregnancy, delivery, and abortion, whether managed through adequate health care systems or not. Abortion
Pregnancy presents a great :isk when it is unwanted and abortion is legally restricted and carried out by untrained practitioners. It is, of course. difficult to obtain wzurate figures for the incidence of clandestine abortion, but Measham and Rochat [24] report that WHO studies in various settings indicate that it ~wmuts for 7-50% of maternal deaths, with a median of 15%. Althoueh it was .lgreed at the International Conf;?rence on Population in M&co City in 1984 that .;bortion was not to be generally considered a method of family planning, it is nevertheless definitely d method of fertility regulation that women have used from time immemorial, and to which thev will continue to turn. whatever the risks. It has been estimated that worldwide there are 30-40 million leaallv - induced abnnions every year. In addition, there are some W-20 mii’;on clandestine abortious every year. This trzxlates into an abortion rate of 37-55 abortions per It?00 women aged 15-W and au abortion ratio of 24-32 per lt?O pregnancies [IZ]. In other words, every year, between 3 and 6% of womeu of reproductive age undergo abortion, and 1 in 4 pregnancies
aze terminated in this way. These very high figures demonstrate a great need for sate, effective and acceptable contraception; for safe pregnancy termination services; and for organized and humane treatmem of abort& compticatians in all circumstausr~, MortaliQ in legal abortions is estimated to be 2 per 100,UOOprocedures in industrialized countries and 6 per 100,ooO in developin countries 119. But dandestine abortion gives rise to very high mortality - 50 deaths per 1OWOO prcced.ares in develcned countries and about 4(10deaths per 100 000 procedures in developing countries 2151.This last figure is probably a substantial underestimate of the dangers of clandestine abortion. Khan [IS] documents 10 deaths in 412 procedures, yielding a death to case rate of 2400 per lW,uU procedures. The most severe consequences of clandestine abortion often occur among poor and iliiterate women in commonities with restrictive abortion laws. 14 rmncb of Latin America, where abortion is banned Iexcept for medical reasons or in cases of rape, it is estimated that 1 in 3 women has had an abortion and that tip :; 50% of materaz? deaths are due to associated complication [HI. In Asia. about 20-23% of maternal deaths are atibutahle to ooorlv oerformed abortion 119.301. In Africa, hospital studies show that abortion-related deaths are increastig. More than 25% of maternal deaths in Lusaka, Zambia [29], and more than 20% in Benin City. Niaeria 1381are due to abortion complicat&~s. - A po&lation-based study conducted in Addis Ababa. Ethiooia. revealed that 50% of maternal mot&ii& resulted from illegal abortion [2!]. Many maintain, wrongly, that abortions are uncommon in Africa. Studies in Nairobi indicate tha; abortions were common in the late 1970s and early 198Os, wheu 24lOO---3ooO women a year were being admitted to Kenyatta Hospital for abortion compkations. Currently, they are treating over 10,GOOcases a year-a five-fold increase 131.A 1987 study in Nigeria showed that abortion is not only a problem of the young and unmarried.
Approximately 30% of septic abortirw were in women over 25 vears old: sour 35% of tho:- who had induced abo&ns were currently married; and about 52% had two or mora children 1271.A hosoiral studv in Ghana found that a&on; obst&ic patients with at least one previous pregnancy, over 20% reported having at least one induced abortion 1221. fioorly performed abortion causes mortalitv. sterilitv. and ill-health. Illenal abortions w&z WO&I~S lives and ruin the chances of their families, but praaching and punishment will not stop them. Given current technology, we need to ask whether permitting such carnage to continue is human or humane. Documentation of the consequences of legai restrictions on abortion is desperately needed as a basis for policy reform. Yet opposition to legal abortion has caused funding for abortion-lclated research to dry up. Any policy that hir;drrs understanding of such a common cause of human suffering and death must be ccwdcred unacceprable and must be fought vigorously. Infertility andSTDs
The problem of infertility is extremely serious in some parts of the world, particularly where the failure to have children can lead to divorce and ostracism. Surveys uave found that an average of 12% of women in subSairaran Africa were childless at the end of their chiidhearing years. although maternal mortality may have reduced the number of fecund women. This compares with a rate of 2-3% in other developing countries 171. Secondary infertility is also a major problem in many areas of Africa. More couples come to African clinics with secondary infertility than in any other part of the world. The two mobt important reasons for this high level of infertility are unhygienic obstetric and abortion procedures and the prevalence of sexually transmitted diseases (STDs), which are extensively reviewed in this issue by Wasserheit. In some areas of Africa. there are indications that 15-30% of young men and women aged 15-24 have contracted an STD
[IO]. The correlation between the prevalence of STDs and HIV infection, which in Africa is killing as many women as men, adds urgency to the calls to include morbidity arising from sexual activity among the problems addressed by reproductive health care programs and policies. Approaching o solution to reproductive health problems Reproductive health problems so deeply rooted in defects in the social, cultural, economic, legal, and political environments are not amenable to a short-term solution. They require a determined, long-term strategy encompassing all aspects of general, equitable development. Fortunately, some reproductive health issues can and do respond to specific actions. Countries and communities need to recognize the complementarity of long- and short-term strategies for solution and plan lhem accordinelv. Among tbe;ost basic long-term solutions will be education, particularly of girls; elimination of nutrition problems; improvement in general economic conditions; repeal of laws inimical to the development of women; elimination of social and cultural practices that discriminate against women and hold them in bondage to inen; and the creation of a political environment in which women are active participants in the evolution of national policies. While achievement of these long-term goals is sought, some relatively short-term developments can make a great deal of difference to the reproductius lives of women. These include .xassive health education campaigns tluouah schools. mass media. wom&‘I organizitions, and othe? chanhels to make citizens understand and use better the services available. Components of reproductive health programs and policies are reviewed below, including services for girls aged S-15 years, famil I) planning, maternity services, and abordon services. Servicesfor girls aged S-15 Girls (and boys) need to know how they
will develop, and the physical and emotional facts and requirements of sexual relationships before they face these events in their own lives. The information should be presented in different ways as the child erows. As well as being appropriate to the age of the child, the information must be culturally seositive. Health care providers working in existing programs - in primary health care, in maternal and child health, in family planning could perhaps team up with schoo!s to provide this information. Parents, teachers, and health care providers must also be made aware of the importance of adequate growth in young and adolescent girls, and of the dangers of deficiencies in diet or nutritional status (e.g. lack of iron, vitamin D. or iodine), which vary from locality to locality. In addition, young people entering their reproductive years~need~o khow the f&s, the’risks, and the kinds of service-s available to them if they are sexu;ll!y active, including family planning, STDs, infertility, otxr reproductive he&h con(izit!s, and mat mity. In areas where few children attend secondary schools, other agencies such as churches. youth groups, and women’s organizations must be encouraged to act. Parents need support and help in discussina these delicate details with their children. It isa parental respolsibitity to see that young people are not placed at risk through igno-
rance. If parents abrogate their resvonsibilitv in this matter, the knowledge may come fro&t harsh experience, or from other sources such as the media of other young people whose messages may well conflict with parental val“es. Peer pressure has an important influence on adolescent behavior, particularIy where changing levels of education are creating a communication gap between the generations. This force can sometimes be used to advantage. The decision whether or not to engage in sexuai activity is ;ULimportant one, and peer group counseling can help the young adolescent learn how to respond to peer pressure. Early female marriage does not avoid the problems related to adolescent fertility: rather, the issues become different. Parents
must roaiiz? that providir,: for girls incindes protecting them from the often considerable health risks of pregr,ancy and childbearing before they are fully grown. R&ions leaders, community !eaders, health w&kers and tsachers must all use their inflcence to discourage marriage before the age of et least 16. Familyplanning
Family planning services help individuals and couples to exercise reproductive choices. These programs should emphasize responsible parenthood and the roles and responsibilities of men, as fathers and as husbands. to USC contraceptives or support their wives’ use. Family &nnin~ . - services should inc!ude abor-
tion counseling where possible, and t;ezt~& of or referral for treatmeat of STDs. Similarly, services must be provided to deal with the problems of inferti!i:y. Family planning has the potential to decrease maternal deaths by reducing the number of pregnancies among women of hi& parity. among women in the age groups carrying most risk, and among women who would risk clandestine illegal abortion Zf faced with an unwanted pregnancy. The major contribution that family planning can make is by reducing fertility. It is estimated that a median of 24% of matomal deaths could be averted by contraceptive use among feexld women not currently using contraception but desiring no further births 1231.Recently, there has been actual evidence of family planning’s effects in this regard. In Matlab, BangIadesh, a clear and consistent differential has emerged between a treatment area with an extensive family planning program and a nearby comparison area. In the ninth year after the stut of the project, although with considerable fluctuation in between, the maternal mortality rate per 100,ooO women of reproductive age in the comparison area was twice the rate in the treatment area [ZOI. Whatever its other contributions, family planning is a right of individuals and couples. For women, it is basic to their ability to control their bodies and enjoy other r:ghts.
Family planning, essential fo: reproductive health, has so many henefits, lo so many people, that its provision should not he confined to MC9 services. MCB pro~atns do not in general reach men, whose participation in hmilv olanninz could make a real contribution ~o’improv&~ents in women’s reproduo. tive health. In addition, they do not reach the unmarried, particularly adolescents. To xhieve reproductive health, the widest possible contraceptive choices are necessarg. Restriction of choices for ideological or ~.ay nther rea~cmleads to poor use of contrace tion. Furthermore, women (and men) may find different methods moie suitable at different times. Given the safety and side-effects of c~rren!!y available methods, women especially need choices among methods. Research ou contraceptive safety is needed in every country to assess the posossibleeffects of particular methods on general health, nUtiand other physiological tional status, conditions specific to the local environment. For many women in the developing world, pregnancy and childbearing take place with little or no trained assistance. Of the 05% of the world’s births that take place in developing countries, less than 50% are attended by a physician, nurse, rnl&ife, or trained treditional birth attendant 1331. In many coontries, fewer than 5O”ioof mothers receive one or more antenatal consultations with a trained person [33]. It appears to be within the capacity of most Loontries to pro\-ide better reproductive health services if they want to. The recent conferences on Safe Motherhood and Better Health for Women and Children Through Family Planning agreed that primary health care (PHC) strateaies should be altered to have a Getter ‘impact on women’s needs. Community antenatal care is essential to ensure that every delivery is assisted by a trained health worker, to provide appropriate and accessible preventive routine care, to facilitate early referral of high risk cases, and to prowde alarm and transportation systems for complicated deiiveries.
Important reductions in mortality could be achieved simply by assuring that safe services are available and accessible to women who qualify for them under existing law. In India, where abortion is allowed on demand UDto 10 weeks of gestation and with medical yeview thereafter, only 1 in 6 abortions are provided by trained providers in safe conaitions 191. In Bangladesh, menstrual regulation services, recognized and supporied as a preventive health service. still reach only lO-20% of the three qua& of a miltion7women who are estonated to attempt to terminate pregnancy every year 191. In many countries, health workers either do not know the laws oc interpret them too narrowly. Teachers and trainers ,3f health care providers, as well as pmviders themselves, need to know the law and act to the full extent possibIe. In many countries, the laws need to be excmined in relation to the realities of women’s needs sod practices, and altered as needed. Where abortion remains restricted, the burden of responsibility lies with governments to ensure adequate access to sex education and contruxp?ion. Over the long term, history tells us that as contraceptive rates rise, abortion rates decline 181.
We bav
seY@ringthe linlx brtween sex and procreation, azd a!! artificial methods of fertility r@gU1ation, with the exception of periodic abstinence, are opposed. In other cases, it is felt that, because contraceptio:: frees sexual activity from the risk of pregnancy sod therefore remov@s the “moral sanction” presented by this risk, contraception will lead to moral laxity and promiscuity. Specific p+pu!ation subgroups may also be denied their right to make decisions about reproductive behavior; for example, parental or sp+x~sal consent might be required, or provision of services denied to adolescents 01 the unmarried. The debate is even more heated with regard to abortion. Where national laws permit, family piatming and other health professionals should be allowed to operate without external pressure from donor governments. Where abortioz are legally restricted, the handling and evmtual treatment o: patients is a human and medical problem. In no other condition is a patient made to feel so humiliated. It is a fact that well-off women who want an abortion badly enough succeed in obtaining it safely, even in the iace of the most stringent laws. The painful truth is that it is usually the poor and the uneducated who are exposed to the gxeatest risk, an example of further discrimination against the most vulcerable members of society. To improve reproductive health. pariicuMy for women, the Safe Motherhood Conference (held in Nairobi in 1987) made a number of recommendations. One highlighted the need to generate political commitment to reallocate :esources to use the knowledge and technol@gies available now. In addition, the conference’s “Call to Action” emphasized that better ha&h and nutrition with services for children ax needed particular attention to the needs of &Is, to ensure they reach their childbearing years in the best of he&h. Girls must dso be piaided with better access to education, which is a key to increasing control over one’s life and environment. Family planning and family life education programs must be expanded, particularly for
young people, and services for planning families must be made more socially, culturally, financially, and geographically accessible. These services must be prusidcd sacb that pregnant Women receive antenatal care, screening. and referral to w&l-equipped and well-staffed facilities and have access to an alarm and transport system in case of @m@[email protected] services must also enable women to avoid unwanted pregnancies or terminate unwanted pregnancies safely, and enable both men and women to rec@ive treatment and counseling for infertility and for SMJS. An integrated approach must be taken to reproductive health care, making it a priority within the context of primary health care. Decision-makers in government, commlmities, and families mu% be reached, so they may change laws and attitudes and improve the legal and health status of women generally, especially in areas such as adolescent marriage and restrictions on health-care delivery. Finally, the community must be mobilized, particularly the women themselves, to pian and implement policies, programs, and projects so their c&s and preferences are explicitly taken into accwnt. One of the statements issued by Third World women from 26 countries and their [email protected] 17 western countries at the 1985 UN Coi.ference on the Decade of Women stated that “women in the Third World denand access to all methods of family p!anning, including abortion as a back-up method, and assert our right to choose for ourselves what is best for us in our situation. By protecting our i&s, we protect the lives of those children that we genuinely want and can care for. TSis is our conception of ‘Pro-Life’ [9].” The rights for which these wome., ask received international silpport long ago. Article 14(t3 of the 1974 World Population Plan of ,-&on states that “alI couples and individuats have the basic right to decide freely and responsibly the number and spacing of their children, and to have the infommtion, education and means to do so....” A right is no right if those for whom it is meant
do not know of its existence, and if services are nor provided to ensure its enjoyment. It is ihe respons;hility of governments and organizations wwking ir. health to ensure that individuals and coudes are aiven access to both the facts and th; services~ In addition to this. s&eties she-uid make aJ! &fort to free their citizens of practices, taboos and consrrahxs which deny them other reproductive rights and freedoms. The most fundamental freedom in this respect comes with the ability to separate sex from reproduction. The benefits of the freedom to use contraceotion were vividly described by Dr. Elizabeth Connell, formerly Associate Professor of Obstetrics and Gvnecoloev at the Columbia Universitv
Medics Sck$, in evidence given before thk Nelson Committee February 24.1970 1371: “As a physician who began to practice before tht advent of the pill, I am constantly aware of the immense difference it has made to the lives of women, to their families, and to society as II whole. The look of horror on the face of a l&year-old giri shen you confirm her fears of pregnancy; the sound of a woman’s voice cursing her newborn and unwanted child as she lies on the delivery table; the absolutely helpless feeling that comes over you as you watch a ‘woman die following criminal abortion; the hideous responsibility of informing a husband and children that their wife and mother has just died in childbirth all these situations are deeply engraved in our memories, never to be forgotten. Since we have had more effective means of contraception, the recurrence of these nightmares has blessedly become less frequent. The thought that we may once again be forced to face these disasters on an increasing scale because of the panic induced by these hearings strikes horror into the hearts of all of us who have lived through this era once before.” Sadly, the gains described here a:e not uniformly available throughout the world. There are some 300 million couples, even today, who do not have access to cortraception. Study after study in many countries iq the
developing world show that the family planning needs of large pclwztages of marrisd women are still noi being met. What is even more disturbing is that &any young people are being comdetelv ianored. The statistics on induced abdrtio&, 0% unplanned pregnancies, and on the heart-rending problems of school dropout due to pregnancy are all warning signs ihat society is discriminating against some very needy persons. in maay developing countries today, the problem of induced abortion is growing, not only among the unmarried or the young, but across society. Where laws are restrictive, it is the poor and uneducated who are denied access to safe abortions. A responsive reproductive he&b cart strategy would attend to the reproductive health needs of all, by providing education for responsible and safe sex life, contraception for the sexually active to use as needed, and services for the management of pregnancy, delivery, and all abortions. It would also provide education and services for the a;evention and management of STDs, subfertd~ly, and iaf&ility. Its goal should be to mai.e lwman sexuality and reprodxtinn a joy - nc _Bcurse orapunishment.
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Oluko~a AA: Reananq rerndnarion: rexI% of a cornmunity-based shzdy in Lagos. Nigtia. Int J Gynecol Obstct>5S: 41. 19!3?. Pandya SK: Y zinzdmgfor baby boys. Br Med J 2%: 1312. ,918.
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Harrison K: Child-baring. health and social priorities: a wvw of 22.174 consecutive hospital births in Zaria, Northern Nigerin. Er I Obstct Gynaol91: 5,198S. Hmshaw SK: Induced abortion: a worldwide perrprcdue. I~l’amPlannPnrpccl 13: 12, ,987. Herr EL Mwhti A: The Safe Motherhood Initiative: Pmposals for Action. “Jashington, DC, The World Rank. 1981. HobbesT:~eLcviatha.MacMillan. NewYark,1651. Hogberg U: Malcrnal moflality - a world wide problem. Int 3 Gynecot Obrtci 2% 463. 1965. How& MM, Glass RI: Parental son prsfwnencc in seeking medical care For children less than fwe years of age in a rural community in Bangladesh. Am J Public Health 78: 1349.1988. Jeffrey P. Lyon *: Female infanticide. and amnioecnteas. SW M Mcd 19: 1207. ,984. Khan AR d 71: Indwicdab:oitior. iii I miid arca of Banglade&~. Stud :‘am PIpon 17: 95.1986. Khan AR n d: Maternal mortality in rural Ben&desh. World HealthForumS: 32S, 1985. Ktig MA et al: Maternal mortality in Matlab. Ban& de&. 19X-1985. Stud Fan Plann 19: 69. 1988. Kvast BlZ d al: Maternal mortality in Addis Ababa. Ethiopia. ShldFnm Platm IZ 288, 1986. Lam9::‘i P :t ak Abotion experience amm,,~ obrtctricpatimtr at KorlrBu Horpiul. Accra. Oh&m. J Bioscc Sci 17: iys. 1985. Maine D: Mcthtrs in peril: th: heavy toll of needlessdeaths. People 12:6,t985. Mcssham AR. Rocba, RW: Slowing the stork: better health for women through family &annin~. A backgound paper prepared for thy lntanationaJ Confcrmce
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World Hdlh orgnni7atiaa: Matcnd Tabulation of Available Informalion.
Mortality R&s 2nd edn. World