23180 Reproductive Health at a glance Why address reproductive health? Being able to choose when to get pregnant, apart from being a health issue, greatly influences popu- Reproductive health (RH) is a state of complete physi- lation growth, and environmental conditions. cal, mental and social well-being and not merely the Increasing contraceptive choices and access leads to absence of disease, in all matters relating to the fewer unsafe abortions--arguably the most easily reproductive system. RH implies that people are able avoidable cause of maternal death. to have a satisfying and safe sex life and that they have the capability and freedom to decide their Life-saving care for complications from abortion is reproductive choices. RH problems such as early and an excellent opportunity to provide contraception, unwanted childbearing, HIV and other sexually trans- avoiding another unwanted pregnancy. mitted infections, and pregnancy-related illness and Reducing pregnancy-related deaths and illness in death account for a significant part of the burden of mothers increases newborn and child survival and disease among adolescents and adults in developing improves productivity. countries. The 1993 World Development Report Reducing maternal deaths depends on a functioning showed that at least 13% of all DALYs were caused health system. Strengthening the system to improve by RH problems. For women the proportion was maternal health brings benefits in many other areas 33%. RH problems are particularly concentrated of health. among the poor who often lack access to minimal RH care. An estimated 120 million women wish to space Reducing violence against women decreases mater- and limit childbearing but lack access to family plan- nal and child morbidity and mortality and ning. Prevention is the most cost-effective approach to unwanted pregnancy, and affirms the value of addressing most RH problems. Serious problems are women in society. costly and very difficult to solve once manifest. The adverse consequences of poor RH, and the benefits Costs of reproductive health care of good RH, extend well beyond health, and have an impact at the societal level. For example, early child- RH care is cost-effective--US$0.90/capita for family bearing can have negative health and social conse- planning, US$3/capita for antenatal and delivery quences for young mothers and lasting effects on care, and US$0.20/capita for STI care--could avert their children. Good RH increases productivity and an estimated 8% of the total global burden of disease well-being. (GBD). In addition, investing US$1.70/capita in HIV/AIDS prevention could avert an additional 2% of Some benefits of reproductive the GBD. health interventions The Millennium Development Goals to which the Improving adolescent reproductive health reduces international community, including the World unwanted pregnancies and the risk of contracting Bank has committed itself, include three goals HIV and other sexually transmitted infections. It addressing RH. These are: improves the chances of girls continuing in school Reduce infant and child mortality rates by and expands their life options. two-thirds between 1990 and 2015. Reduce maternal mortality ratios by three Providing life coping skills including RH education for boys and girls has long term positive impacts. quarters between 1990 and 2015. Stop and begin to reverse the spread of Prevention and management of sexually transmitted HIV/AIDS by 2015. infections (STIs) prevents sexual spread of HIV. Integrating HIV prevention activities in mother and The main interventions to improve reproductive health child health (MCH) and family planning (FP) pro- can be grouped: grams addresses missed opportunities to curb the reduce unplanned pregnancies and poorly timed HIV epidemic in the general population. pregnancies March 2002 improve prenatal and delivery care, including care at all times and equipped with adequate operating of obstetric emergencies facilities, safe blood supplies and medicines. increase the number of skilled providers Transport and communication are also required, and families and communities need to be motivated to reduce the risk of STIs, including HIV/AIDS take action to save the life of a mother (and her child) reduce harmful practices and violence against when an emergency occurs. women 3. Plan to increase the number of skilled providers. address contextual factors: poverty, women's Since much of RH care--and especially professional- education and status, lack of male involvement, ization of birthing care--depends on skilled care and needs of adolescents providers, long-term strategic human resource plan- ning and training cannot be emphasized enough. How to improve reproductive health 4. Reduce the risks of STI and HIV Infections. Unsafe 1. Reduce unplanned and poorly timed pregnancies sex increases the risk of contracting reproductive tract and the health risks associated with them. Include an infections and HIV/AIDS. The risk of HIV infection appropriate array of high quality, consumer-oriented increases for women and men with lesions associated family planning information and services in with other reproductive tract infections. Management benefits/service packages offered by public and pri- and treatment of STIs can substantially reduce that vate providers, and extend these services to hard-to- risk. Use of condoms and reducing the number of reach groups (youths, poor rural and urban people, sexual partners are effective preventive measures that and high risk groups) through outreach and social can be supported through targeted interventions for marketing programs. high risk groups, health education, promotion and community mobilization. Screening and counseling For women who resort to abortion to end an for those who are infected are also effective. unwanted pregnancy, it is important that abortion services are safe and also that post-abortion services 5. Address harmful practices. Female genital mutila- are provided, including guidance on contraceptive tion (FGM) is associated with complications of methods to avoid further unwanted pregnancies. pregnancy and delivery and with sexual dysfunction. Training and re-training of providers is also needed to Because the practice is culturally ingrained, measures maintain high technical quality of service provision, to reduce it need to work at several levels and effective approaches to counseling and attention to engage the community, practitioners and policy- client needs. makers. Domestic violence also contributes to poor reproductive health outcomes. Providers need to be 2. Reduce maternal mortality and morbidity by trained to recognize the signs of violence, to use improving prenatal and delivery care and by ensur- appropriate approaches to treatment and counseling, ing effective management of obstetric emergencies. and to involve communities. The World Health Organization has developed practical guidelines on maternal care that can reduce 6. Address factors beyond health care that affect the health risks during pregnancy, delivery and the reproductive health outcomes. Contextual factors, post partum period. Prenatal care and treatment for including poverty, malnutrition and the low status of anemia, high blood pressure/edema and other women, as well as attitudes and behaviors of individ- complications are very cost effective. uals, the community and providers can positively or negatively influence reproductive health outcomes. Ensuring that every delivery is attended by a trained The design of interventions needs to take account of midwife or qualified health worker is a key interven- forces outside the formal health system. Many of tion to reduce maternal death and illness. Obstetric those who are at risk, youth as well as men, do not emergencies can occur with any delivery, so atten- use clinical services provided though the health dants need to know how to recognize and respond to system and require special outreach initiatives. trouble signs. Referral to facilities that can manage Countries need to look beyond the health system to complications such as hemorrhage, obstructed labor deal with HIV/AIDS and problems such as poverty and sepsis, is also required. Referral centers need to reduction, and gender equality. be staffed with trained providers who are available Objectives Core Interventions Beneficiaries Indicators 1. Reduce health risks of unwanted pregnancies Reduce unplanned and poorly- Expand family planning services through community-based Men and women of Total fertility rate timed pregnancies workers, social marketing and health facilities. reproductive age Contraceptive prevalence rate Unmet need for spacing and limiting births (DHS data) Age at first birth Reduce the risk of unsafe Ensure safety of abortion where not against the law and Pregnant women, % of gynecological admissions that are for abortion- abortion provide post-abortion care and family planning information especially adolescents related complications and services. Case fatality rate for post-abortion complications 2. Reduce health risks of pregnancy and delivery Reduce delays in recognizing Ensure prompt detection, management, and referral of Pregnant women and their Maternal mortality ratio and managing complications of complications. infants % of deliveries with skilled attendant pregnancy and delivery Train staff in midwifery skills at all levels of the health system. Maternal and perinatal death reviews % of low-birthweight babies Improve the capacity of the Ensure early antenatal contact for care, counseling, and Pregnant women and their % of pregnant women receiving antenatal care at health system to give quality birth planning. infants least once maternal-newborn care Improve quality of ANC, delivery, postpartum & newborn % of pregnant women who are anemic care through competency-based training and supervision. Number and distribution of basic and comprehensive Stress life-saving skills. essential obstetric care facilities/500,000 pop. Remove barriers that keep poor Promote community financing programs. Promote private Poor women % of poor women who deliver with skilled attendant women from access to services for those who can afford it and assure public funds maternity care are used to finance transportation and care for the poor. 3. Reduce STI and HIV Infections Reduce high-risk behaviors, Educate men, women and youth about family planning and Men and women, Age at sexual debut; prevalence of casual sexual particularly among youth and safe sex, and promote condoms that can be obtained particularly youth encounters without protection other high risk groups through a variety of channels and behavior change Prevalence of condom use communication. Provide services for men and promote male Prevalence of STIs involvement. Reduce incidence/prevalence Ensure availability of services for RTIs/STIs and treatment for Men and women of Case detection, treatment and cure rates of RTIs/STIs, including other health conditions. reproductive age HIV/AIDS Provide appropriate laboratory equipment and drugs. 4. Reduce the prevalence of harmful practices that undermine women's health Reduce prevalence of FGM Work with community groups to find alternative rituals for Adolescent women % of women reporting that they have undergone FGM initiation and/or alternative employment for individuals who perform FGM. Target national and community leaders where performed. Reduce violence against Improve education of men and women about laws and All women Incidence of rape women educate about effects of violence on women and society. Violent death rate among women Support involvement of women's groups. 5. Improve status of women in society Create an enabling Improve education and nutrition for girls. Provide credit Women, particularly Female secondary school gross enrollment rate environment for improvements and better employment opportunities for women. Improve adolescents Stunting among girls in reproductive health outcomes health communications capacity. Support involvement of women's groups and men in reproductive health and rights. Implement poverty reduction strategies. Do's and Don'ts DO invest in women's reproductive health earlier in the life cycle. By treating protein-energy and iron/ DO pay attention to demand and access. Investments folate deficiency in adolescents, young women will in health education and communication can increase better tolerate the increased demands of pregnancy, utilization but have limited effect on demand for RH birth and lactation. The chances for a normal birth, care. Improvements in women's status through educa- resulting in normal birth weight and optimal growth tion and economic opportunity have a strong influ- and development of the baby are strengthened. ence on demand for RH services, including family planning and delivery care. DO encourage male involvement for better promotion of responsible sexuality. Men and women need equal DO pay attention to client perspectives and quality. access to information, education and services. Programs that pay attention to consumers work better than those that impose top-down targets and serve DON'T neglect the disadvantaged and hard to reach the needs of providers rather than consumers. groups. An effective way to serve the needs of high Incentives that promote positive provider attitudes and risk groups and the poor is to involve community behavior are more effective than targets and punitive groups and NGOs. management practices. Resources DON'T assume that improved performance has to cost a lot. Many countries have achieved better RH World Bank, 1999, Intensifying Action Against outcomes by using their existing resources more effec- HIV/AIDS in Africa: Responding to a development tively by building strong political and grassroots sup- crisis, Washington, D.C. port for improved RH outcomes. Improving the quality ___, 1999, Population and the World Bank: of family planning care is a good example of this. Adapting to Change, Washington, D.C. ___, 1999, Safe Motherhood and the World Bank: DON'T neglect behavior change. This is required for Lessons from 10 Years of Experience, Washington, individuals, families, communities and providers if D.C. reproductive health outcomes are to improve. Effective health promotion and communications have ___, 2000, Improving Women's Health: Issues and contributed to better RH outcomes by reducing risky Interventions, Washington, D.C. practices (unprotected sex), promoting positive ones ___, 2000, Contracting-out for Reproductive Health: (better hygiene and nutrition), and making providers A Guide, Washington, D.C. more attentive to the needs of their clients. ___, 2001, Condom Procurement Guide, Washington, D.C. DO plan for the long term to reduce maternal mortal- ity. Long-term efforts are required to improve capacity for management of obstetric emergencies and to pro- Useful Web sites fessionalize birthing care. The Population and RH Thematic Group Portal on the Bank's Intranet DO involve adolescents in RH programs both on the information side (in schools and to out of school http://www.unfpa.org/icpd/ youth) and in the provision of youth friendly RH serv- http://www.who.int/reproductive-health/index.htm ices. http://www.safemotherhood.org/ DON'T neglect cervical cancer prevention. Programs http://www.unaids.org/ can work in poor country settings, but need careful http://www.rho.org planning to be feasible and effective. For further information contact Elizabeth Lule in the DO aim to reduce violence against women. This is World Bank HNP Anchor elule@worldbank.org , one example of putting women's rights in focus, and Khama Rogo in the World Bank Africa Region an effective way of mobilizing society's resources to krogo@worldbank.org or Kimberly Switlick improve RH outcomes. kswitlick@worldbank.org Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp