REPRODUCTIVE HEALTH A LIFE CYCLE APPROACH

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REPRODUCTIVE HEALTH A LIFE CYCLE APPROACH

• DR ABIDA SULTANA
• MBBS.MCPS.FCPS.
• Head of Department
• Community Medicine

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HADITH of today

• No believing man hates his believing wife. If
  there is a bad habit in her, there will be other
  lovable qualities(Muslim)

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OBJECTIVES OF TODAY

• To introduce a paradigm shift in the reproductive
  health.
• To teach the differences between MCH and
  reproductive health.
• To elaborate the different components of the
  package of RH.
• To describe the different strategies to achieve
  the goals of RH Package.

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OBJECTIVES OF PARADIGM SHIFT

• To introduce the new concept of Paradigm shift.
• To give the rationale of RH concept covering the
  entire span of life that is Life cycle approach.
• To explain RIGHTS BASED APPROACH
• To elaborate the newer ROLE OF MAN in child
  birth.
• To differentiate the concept of F.P. services
  from RH.

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REPRODUCTIVE HEALTH CARE

• The old paradigm (before 1994)
• 1 FAMILY PLANNING
• Unmet need for contraception
• 2 MATERNAL CARE
• Antenatal care
• Safe child birth
• Post-partum care

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BEFORE 1994 (cont)

• 3 CHILD HEALTH CARE
• Breast feeding promotion
• Nutrition
• Growth monitoring
• Immunization
• Sickness care (ORT, ARI, malaria etc)

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ICPD PARADIGM SHIFT(in 1994)

• International Conference on Population and
  Development.
• 1994 Cairo.
• To move beyond a narrow focus on family planning
  to a more comprehensive program of integrating
  population and health activities that would help
  individuals to meet their Reproductive Health
  needs.

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ICPD PARADIGM SHIFT (cont)

• Provision of family planning services within a
  broader type of reproductive health service
• Interrelation of Reproductive Health with
  policies to empower women, strengthen families,
  stabilize population growth and eradicate
  poverty.
• Improve women's equality in education, health and
  economic opportunities.

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ICPD PARADIGM SHIFT (cont)

• Special focus on fulfilling womens health needs,
  safe guarding their reproductive rights and
  involving men as equal partners in meeting the
  goal of responsible parenthood.
• Shift to Rights Based Approach
• Shift away From macro concerns at population
  level for reduction in its growth for
  achievements of stabilization To micro concern at
  individual level for improvement in well being.

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REPRODUCTIVE HEALTH

• A state of complete physical, mental and social
  well being and not merely the absence of disease
  or infirmity, in all matters relating to the
  reproductive system and to its functions or
  process

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MATERNAL MORTALITY A GLOBAL TRAGEDY
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MATERNAL MORTALITY A GLOBAL TRAGEDY

• Annually, 585,000 women die of pregnancy related
  complications
• 99 in developing world
• 1 in developed countries

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GLOBAL MATERNAL DEATH WATCHEVERY MINUTE
Every Minute...

• 380 women become pregnant
• 190 women face unplanned or unwanted pregnancy
• 110 women experience a pregnancy related
  complication
• 40 women have an unsafe abortion
• 1 woman dies from a pregnancy-related complication

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GLOBAL CAUSES OF MATERNAL MORTALITY
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What determines Reproductive Health?

• Fetal wellness
• Social context (community, household, family)
• _ nutrition, education, housing, income
• Environment
• _ Safe water, no toxic exposure
• _ Health services access and quality
• Personal efficacy
• _ Health competence
• _ Health care seeking

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CURRENT DATA OF PAKISTAN

• Fertility (per woman) 4.3
• Awareness about contraception 96
• Contraceptive prevalence rate 34
• MMR per 100,000 births 350-400
• IMR per 1000 births 77
• Child MR per 1000 births 103
• Source Pakistan Economic
• Survey 2007

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But WHY Do These Women Die?
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DETERMINANTS OF MATERNAL MORTALITY

• 1. Age at child birth (Too Early, Too
  Late)
• 2. Parity (Too Many)
• 3. Too close pregnancies (Too Close)
• 4. Family size
• 5. Malnutrition
• 6. Poverty
• 7. Illiteracy
• 8. Ignorance and prejudices

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DETERMINANTS (cont)

• 9. Lack of maternity services
• 10.Shortage of health manpower
• 11.Delivery by untrained dais
• 12.Poor environmental sanitation
• 13.Poor communication and transport
• facilities
• 14.Social customs

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THREE DELAYS MODEL

• Delay in decision to seek care
• Lack of understanding of complications
• Acceptance of maternal death
• Low status of women
• Socio-cultural barriers to seeking care
• Delay in reaching care
• Mountains, islands, rivers poor organization
• Delay in receiving care
• Supplies, personnel
• Poorly trained personnel with punitive attitude
• Finances

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REPRODUCTIVE HEALTH PACKAGE
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REPRODUCTIVE HEALTH PACKAGE

• Comprehensive family planning facilities and care
• Safe motherhood, abortions
• Infant health care
• Adolescents R.H. problems
• RTIs/ STDs/ HIV/ AIDS/ HBV/ HCV prevention, early
  detection and management

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REPRODUCTIVE HEALTH PACKAGE (cont)

• 6. Infertility
• 7. Cancer cervix, breast, detection and
  management
• 8. Other RH problems of women
• 9. Other RH problems of men

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1. COMPREHENSIVE F.P. SERVICES FOR

• Information about availability, advantages,
  efficacy, side effect, contraindications of
  contraceptives, including natural methods.
• Availability and provision of different methods
  with safety and quality.
• Appropriate screening of clients.
• Supportive counseling.
• Management of side effects.
• Follow-up.

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2. SAFE MOTHERHOOD

• Antenatal registration and care.
• Treatment of existing conditions (e.g. anemia,
  malaria).
• Advice regarding nutrition and diet.
• Iron/folate supplementation.
• Essential obstetric care (EOC).
• Clean and safe (atraumatic) delivery.

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SAFE MOTHERHOOD (cont)

• g. Early detection and management of postpartum
  complications.
• h. Prevention and management of urinary and
  rectal fistulae and prolapse.
• i. Genetic counseling.
• j. Blood test during pregnancy for Rh
  incompatibility.
• k. Tetanus immunization .

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PRE / POST ABORTION CARE FOR COMPLICATIONS

• Create awareness about dangers of abortion.
• Detection and early management of complications
  of abortion.
• Counseling to post abortion cases including
  advice regarding F.P. to avoid recurrence.

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3. INFANT HEALTH CARE

• Resuscitation of the newborn.
• Early and exclusive breast feeding.
• Management of infection (ophthalmia neonatorum
  and cord infections).
• Congenital abnormalities.
• L.B.W and malnutrition management.
• Weaning.
• Safe and aseptic circumcision.
• Immunization.

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4. MANAGEMENT OF RH PROBLEMS OF ADOLESCENTS

• Education of normal physiological changes at
  puberty.
• Management of problems as dysmenorrhea hirsutism,
  sexual abuse, vaginal discharge etc.
• Personal hygiene.
• Detection and management of congenital
  abnormalities, imperforate hymen, early / delayed
  menarche.

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• 5. PREVENTION AND MANAGEMENT OF RTIs/STDs AND
  HIV/AIDS
• Information for prevention.
• Screening and management.
• 6. MANAGEMENT OF INFERTILITY
• Information for prevention.
• Management of allied problems.
• Investigations and early treatment.

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7. DETECTION OF CANCER

• BREAST
• Inform and train for self examination.
• Early detection and management.
• Screening for breast lumps.
• Supporting, counseling, rehabilitation.
• CERVICAL
• Pap smear.
• Early detection and management.

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8. MANAGEMENT OF OTHER RH PROBLEMS OF WOMEN

• Awareness and management of pre and menopausal
  syndrome.
• Detection and management of menopause related
  deficiencies.
• Management of sexual dysfunction as loss of
  libido and dyspareunia.
• Management of post menopausal circulatory
  diseases.

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9. MANAGEMENT OF RH RELATED PROBLEMS OF MEN

• Adolescent health
• Counseling, motivation for F.P. RH rights of
  women and responsible parenthood.
• Male involvement in antenatal, natal and post
  natal care of woman.
• Counseling on main sexual problems and
  dysfunctions.
• Counseling for prevention of RTIs/STDs and
  treatment of infertility.
• Detection and management of cancer and related
  problems.

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LIFE CYCLE APPROACH TO REPRODUCTIVE HEALTH
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LIFE CYCLE APPROACH TO REPRODUCTIVE HEALTH

• Infancy and childhood (0-9yrs)
• Adolescents (10-19 yrs)
• Reproductive years (20-44 yrs)
• Post reproductive years (45 yrs)

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LIFE CYCLE APPROACH TO DEFINE WOMEN'S LIFE TIME
HEALTH PROBLEMS
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Infancy childhood (0-9 yrs)

• Sex selection
• Genital mutilation
• Discriminatory nutrition
• Discriminatory health care
• Gender ID /modeling
• Behavior
• Aggression
• Education

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Adolescents (10-19 yrs)

• Early child bearing
• Abortion
• STIs/AIDs
• Under nutrition- macro micro
• Rising trend of substance abuse
• Acne
• Physiological changes in the body
• Secondary sex characteristics
• Aggression
• Violence/abuse
• Gender discrimination

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Reproductive Years (20-44 yrs)

• Unplanned pregnancy
• STIs/AIDs
• Abortion
• Pregnancy complications
• Malnutrition
• Pregnancy
• Child bearing and rearing
• Contraception
• Abuse and violence

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Post-Reproductive years (45 yrs)

• Cardio-vascular diseases
• Gynecological cancers
• Osteoporosis
• Osteoarthritis
• Diabetes
• Cancers
• Sexual dysfunction
• Sub fertility/infertility
• STD/HIV
• Menopause

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RIGHT BASED APPROACH
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THE RIGHT

• TO attain the highest standard of sexual and
  reproductive health throughout the life cycle.
• For reproductive self determination including
• Right to voluntary choice in marriage
  
• Right to decide freely the number,
  timings
• and spacing of children and to have
  means
• to do so.
• OF Sexual and Reproductive Security including
  freedom from sexual violence and coercion.
• OF Equality and Equity for men and women in all
  spheres of life.

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ADDITIONAL ISSUES with the new paradigm
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Reproductive health care Addition with the new
paradigm

• 1. GENDER DISCRIMINATION
• Sex selective abortions
• Son preference for food allocation, health care,
  education, etc
• 2. VIOLENCE AGAINST WOMEN
• Child pornography
• Commercial sex
• Female genital mutilation
• Spouse abuse
• Rape, incest (cont)

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Reproductive health care Addition with the new
paradigm

• 3. ADOLESCENT SEXUALITY
• 4. REPRODUCTIVE RIGHTS regarding marriage and
  childbearing
• 5. GENDER EQUITY AND EQUALITY
• 6. UNINTENDED PREGNANCY
• Emergency contraception
• Safe abortion (cont)

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Reproductive health care Addition with the new
paradigm

• 7. CHRONIC COMPLICATIONS OF PREGNANCY AND
  CHILDBIRTH
• 8. SEXUALLY TRANSMITTED DISEASES
• Acute infections
• Chronic complication, e.g.
• infertility
• cervical cancer
• 9. HIV / AIDS

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REPRODUCTIVE HEALTH INTERVENTIONS
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REPRODUCTIVE HEALTH INTERVENTIONS FOR FEMALES

• Preconception care (family planning)
• Family life education
• Antenatal care and nutrition
• Delivery and postnatal care
• Reproductive Tract Infection (RTI) Care
• Sexual Health (STI, HIV / AIDS)
• Reproductive cancer treatment
• Other reproductive function

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REPRODUCTIVE HEALTH INTERVENTIONS FOR MALES

• Preconception care (family planning)
• Adolescent health
• Male involvement in Antenatal care, Delivery and
  Postnatal care of woman
• Reproductive Tract Infection (RTI) Care
• Sexual Health (STI, HIV / AIDS)
• Reproductive cancer treatment
• Other reproductive functions

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HARMFUL TRADITIONAL REPRODUCTIVE HEALTH PRACTICES
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• Early marriage
• Female Genital Cutting/Mutilation (FGM)
• Dry sex practices
• Dietary and other restrictions during pregnancy
• Heavy work during pregnancy
• Withholding colostrums from newborn

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GENDER AND REPRODUCTIVE HEALTH
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SEX

• Biological.
• Refers to visible differences in genetalia.
• Related differences in procreative functions.
• Constant, can not be changed.

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GENDER

• Socio-economically determined.
• A culture.
• Refers to masculine and feminine qualities,
  behavior patterns, roles and responsibilities
  etc.
• A variable, not constant.

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GENDER AND LIFE CYCLE OF PAKISTANI WOMANA Summary
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• Before conception sex selective technology.
• In uterus sex selective abortion.
• New born female infanticide.
• Infancy benign neglect.
• Childhood poor health care seeking/ access.
• Adolescence. lack of education/ illiteracy/
  sexual violence.
• Adulthood reproductive morbidity/ mortality,
  dowry deaths.
• Old age.

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MILLENNIUM DEVELOPMENT GOALS
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GOAL 1 Eradicate extreme poverty and hunger

• Reduce by half the proportion of people living on
  less than a dollar a day.
• Reduce by half the proportion of people who
  suffer from hunger.

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Goal 2 Achieve universal primary education

• Ensure that all boys and girls complete a
• full course of primary education.

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Goal 3 Promote gender equality and
empower women

• Eliminate gender disparity in primary and
• secondary education preferably by 2005,
• and at all levels by 2015.

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Goal 4 Reduce Child mortality

• Reduce by two thirds the mortality rate
• among children under five.

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Goal 5 Improve maternal health

• Reduce by two three quarters the
• maternal mortality ratio.

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Goal 6 Combat HIV / AIDS, Malaria and other
diseases

• Halt and begin to reverse the spread of HIV/AIDS
• Halt and begin to reverse the incidence of
  malaria and other major diseases.

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QUALITY OF CARE
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• The way individuals and clients are treated by
  the system providing services.
• Six elements.
• 1. Choice of methods of contraception.
• 2. Information given to clients.
• 3. Technical competence. Protocol. Clinical
  techniques. Meticulous asepsis.
• 4. Interpersonal relations, between provider and
  client.
• 5. Mechanism to encourage continuity.
• 6. Appropriate constellation of services.

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FACTORS INFLUENCING PROVISION OF RH SERVICES
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• Number of service delivery points.
• Geographical, physical and social accessibility.
• Proper advertisement of services.
• Quality of care.

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QUALITY OF CARE

• Opening and closing timings.
• General cleanliness.
• Maintenance of privacy.
• Proper waiting area.
• Trained staff.
• Availability of range of services (medicine/
  equipments).
• Client/ provider interaction.

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RH SERVICES OUTLETS IN PAKISTAN
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Public sector programs

• 1. Community Based Services.
• National Program for Family Planning and PHC.
• 72,000 Lady Health Workers, one for 1000 women.
• 21,304 trained midwives.

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Public sector programs

• 2. Family Based Services.
• MCH Centers. 906 in number. Run by LHV.
• BHUs. 5,301. one for 5-10,000 people.
• Two inpatient beds. Medical officer. Staff of 10.
• RHCs. 552. one for 25-50,000 people. Staff of
  30.Ten to twenty beds.
• THQs. One for 100-300,000 people.
• DHQs. One for 1-2 million people.
• Specialized institutions/ Teaching
• hospitals.

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PRIVATE SECTOR PROGRAMS.

• 1. Qualified doctors.
• GP (general practitioners)
• Specialists.
• 2. Unqualified practitioners (quacks).
• 3. Hakeems.
• 4. Homeopaths.
• 5. Tibb or Unani medicine.
• 6. NGOs as Rozan and Sahil in Punjab, Aahung in
  Sindh.

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CLIENT/ PROVIDER INTERACTION
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SAHR

• SALUTATION greet/ ice breaking, assure client,
  show patience.
• ASSESS decision making about other RH problems
  of client.
• HELP encourage client to speak, inform about
  options, cost, time etc.
• REASSURE request client to repeat her solution.
  reassure about solution.

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THANK YOU