Reproductive health

Within the framework of the World Health Organization's (WHO) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system at all stages of life.^[1] Reproductive health implies that people are able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. One interpretation of this implies that men and women ought to be informed of and to have access to safe, effective, affordable and acceptable methods of birth control; also access to appropriate health care services of sexual, reproductive medicine and implementation of health education programs to stress the importance of women to go safely through pregnancy and childbirth could provide couples with the best chance of having a healthy infant.

Individuals do face inequalities in reproductive health services. Inequalities vary based on socioeconomic status, education level, age, ethnicity, religion, and resources available in their environment. It is possible for example, that low income individuals lack the resources for appropriate health services and the knowledge to know what is appropriate for maintaining reproductive health.^[2]

The WHO assessed in 2008 that "Reproductive and sexual ill-health accounts for 20% of the global burden of ill-health for women, and 14% for men."^[3] Reproductive health is a part of sexual and reproductive health and rights.

According to the United Nations Population Fund (UNFPA), unmet needs for sexual and reproductive health deprive women of the right to make "crucial choices about their own bodies and futures", affecting family welfare. Women bear and usually nurture children, so their reproductive health is inseparable from gender equality. Denial of such rights also worsens poverty.^[4]

Reproductive health should be looked at through a lifecycle approach as it affects both men and women from infancy to old age. According to UNFPA, reproductive health at any age profoundly affects health later in life.^[4] The lifecycle approach incorporates the challenges people face at different times in their lives such as family planning, services to prevent sexually transmitted diseases and early diagnosis and treatment of reproductive health illnesses. As such, services such as health and education systems need to be strengthened and availability of essential health supplies such as contraceptives and medicines must be supported.

Sexual health

A WHO working definition for sexual health is that it "is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled."^[5] However, while used by WHO as well as other organizations, this is not an official WHO position, and should not be used or quoted as a WHO definition.^[5]

The programme of action (PoA) of the International Conference on Population and Development (ICPD) in Cairo in 1994 was the first among international development frameworks to address issues related to sexuality, sexual and reproductive health, and reproductive rights. The PoA defined sexual health as, dealing “with the enhancement of life and personal relations, not merely counseling and care related to reproduction and sexually transmitted diseases.19 It refers to the integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love.” ^[6]

Emerging research in the field of sexual and reproductive health (SRH) identifies a series of factors that enhance the translation of research into policy and practice.^[7] These include discursive changes (creating spaces for public debate); content changes (to laws and practices); procedural changes (influencing how data on SRH are collected) and behavioural changes (through partnerships with civil society, advocacy groups and policy makers).^[7]

Childbearing and health

Early childbearing and other behaviours can have health risks for women and their infants. Waiting until a woman is at least 18 years old before trying to have children improves maternal and child health.^[8][9] If an additional child is to be conceived, it is considered healthier for the mother, as well as for the succeeding child, to wait at least 2 years after the previous birth before attempting to conception.^[8] After a fetal fatality, it is healthier to wait at least 6 months.^[8]

The WHO estimates that each year, 358 000 women die due to complications related to pregnancy and childbirth; 99% of these deaths occur within the most disadvantaged population groups living in the poorest countries of the world.^[10] Most of these deaths can be avoided with improving women's access to quality care from a skilled birth attendant before, during and after pregnancy and childbirth.

Availability of modern contraception

Modern contraception is often unavailable in certain parts of the world. According to the WHO, about 222 million women worldwide have an unmet need for modern contraception, and the lack of access to modern contraception is highest among the most disadvantaged populations: the poor, those living in rural areas and urban slums, those living with HIV, and those who are internally displaced.^[11] In developing parts of the world, the lack of access to contraception is a main cause of unintended pregnancy, which is associated with poorer reproductive outcomes.^[11] According to UNFPA, access to contraceptive services for all women could prevent about one in three deaths related to pregnancy and childbirth.^[12]

Female genital mutilation

Prevalence of FGM by country, according to a 2013 UNICEF report^[13]

Female genital mutilation (FGM), also known as female genital cutting or female circumcision, "comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons".^[14][15] The practice is concentrated in 29 countries in Africa and the Middle East; and more than 125 million girls and women today are estimated to have been subjected to FGM.^[14] FGM also takes place in immigrant communities in Western countries, such as the UK.^[16]

FGM does not have any health benefits, and has negative effects on reproductive and sexual health, including severe pain, shock, hemorrhage, tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue, recurrent bladder and urinary tract infections, cysts, increased risk of infertility, childbirth complications and newborn deaths. FGM procedures that seal or narrow a vaginal opening (known as type 3) lead to a need for future surgeries of cutting open in order to allow for sexual intercourse and childbirth.^[14]

According to UNFPA, “FGM violates human rights principles and standards – including the principles of equality and non-discrimination on the basis of sex, the right to freedom from torture or cruel, inhuman or degrading punishment, the right to the highest attainable standard of health, the rights of the child, and the right to physical and mental integrity, and even the right to life, among others.^[15]

Sexually transmitted diseases

Estimated prevalence in % of HIV among young adults (15–49) per country as of 2011.^[17]

No data   <0.10   0.10–0.5   0.5–1

1–5   5–15   15–50

Sexually transmitted diseases (STD), also referred to as sexually transmitted infections (STI) or venereal diseases (VD), are illnesses that have a significant probability of transmission between humans by means of sexual activity. Common STDs include chlamydia, gonorrhea, herpes, HIV/AIDS, hepatitis B, human papillomavirus (HPV), syphilis, trichomoniasis.^[18][19]

Sexually transmitted infections affect reproductive and sexual health, having a profound negative impact worldwide.^[20] Programs aimed at preventing STIs include comprehensive sex education, STI and HIV pre- and post-test counseling, safer sex/risk-reduction counseling, condom promotion, and interventions targeted at key and vulnerable populations.^[20] Having access to effective medical treatment for STIs is very important.

Adolescent health

Teenage birth rate per 1,000 females aged 15–19, 2000–2009^[21]

Issues affecting adolescent reproductive and sexual health are similar to those of adults, but may include additional concerns about teenage pregnancy and lack of adequate access to information and health services. Worldwide, around 16 million adolescent girls give birth every year, mostly in low- and middle-income countries.^[22] The causes of teenage pregnancy are diverse. In developing countries girls are often under pressure to marry young and bear children early (see child marriage). Some adolescent girls do not know how to avoid becoming pregnant, are unable to obtain contraceptives, or are coerced into sexual activity.^[22] Adolescent pregnancy, especially in developing countries, carries increased health risks, and contributes to maintaining the cycle of poverty.^[23] The availability and type of sex education for teenagers varies in different parts of the world. LGBT teens may suffer additional problems if they live in places where homosexual activity is socially disapproved and/or illegal; in extreme cases there can be depression, social isolation and even suicide among LGBT youth.

UNFPA recommends “Comprehensive sexuality education” (CSE) as it enables young people to make informed decisions about their sexuality.^[24] According to the UNFPA, CSE should be taught by introducing content which is age-appropriate to the capacities of young people over a span of several years. The curriculum includes scientifically accurate information on physical development, anatomy, pregnancy, contraception and sexually transmitted infections (STIs), including HIV. It should encourage confidence and skills for communication topics include social issues around sexuality and reproduction.^[24]

International Conference on Population and Development, 1994

The International Conference on Population and Development (ICPD) was held in Cairo, Egypt, from 5 to 13 September 1994. Delegations from 179 States took part in negotiations to finalize a Programme of Action on population and development for the next 20 years. Some 20,000 delegates from various governments, UN agencies, NGOs, and the media gathered for a discussion of a variety of population issues, including immigration, infant mortality, birth control, family planning, and the education of women.

In the ICPD Program of Action, 'Reproductive health' is defined as:

a state of complete physical, mental and social well-being and...not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed [about] and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of birth control which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.^[25]

This definition of the term is also echoed in the United Nations Fourth World Conference on Women, or the so-called Beijing Declaration of 1995.^[26] However, the ICPD Program of Action, even though it received the support of a large majority of UN Member States, does not enjoy the status of an international legal instrument; it is therefore not legally binding.

The Program of Action endorses a new strategy which emphasizes the numerous linkages between population and development and focuses on meeting the needs of individual women and men rather than on achieving demographic targets.^[27] The ICPD achieved consensus on four qualitative and quantitative goals for the international community, the final two of which have particular relevance for reproductive health:

• Reduction of maternal mortality: A reduction of maternal mortality rates and a narrowing of disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups.
• Access to reproductive and sexual health services including family planning: Family planning counseling, pre-natal care, safe delivery and post-natal care, prevention and appropriate treatment of infertility, prevention of abortion and the management of the consequences of abortion, treatment of reproductive tract infections, sexually transmitted diseases and other reproductive health conditions; and education, counseling, as appropriate, on human sexuality, reproductive health and responsible parenthood. Services regarding HIV/AIDS, breast cancer, infertility, delivery, hormone therapy, sex reassignment therapy, and abortion should be made available. Active discouragement of female genital mutilation (FGM).

The keys to this new approach are empowering women, providing them with more choices through expanded access to education and health services, and promoting skill development and employment. The programme advocates making family planning universally available by 2015 or sooner, as part of a broadened approach to reproductive health and rights, provides estimates of the levels of national resources and international assistance that will be required, and calls on governments to make these resources available.

Millennium Development Goals

Achieving universal access to reproductive health by 2015 is one of the two targets of Goal 5 - Improving Maternal Health - of the eight Millennium Development Goals.^[28] To monitor global progress towards the achievement of this target, the United Nations has agreed on the following indicators:

• 5.3: contraceptive prevalence rate
• 5.4: adolescent birth rate
• 5.5: antenatal care coverage
• 5.6: unmet need for family planning

According to the MDG Progress Report, regional statistics on all four indicators have either improved or remained stable between the years 2000 and 2005.^[29] However, progress has been slow in most developing countries, particularly in Sub-saharan Africa, which remains the region with the poorest indicators for reproductive health.^[30] According to the WHO in 2005 an estimated 55% of women do not have sufficient antenatal care and 24% have no access to family planning services.^[30]

Reproductive health and abortion

An article from the World Health Organization calls safe, legal abortion a "fundamental right of women, irrespective of where they live" and unsafe abortion a "silent pandemic".^[31] The article states "ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative." It also states "access to safe abortion improves women’s health, and vice versa, as documented in Romania during the regime of President Nicolae Ceaușescu" and "legalisation of abortion on request is a necessary but insufficient step toward improving women’s health" citing that in some countries, such as India where abortion has been legal for decades, access to competent care remains restricted because of other barriers. WHO’s Global Strategy on Reproductive Health, adopted by the World Health Assembly in May 2004, noted: “As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the MDG on improving maternal health and other international development goals and targets." ^[32] The WHO's Development and Research Training in Human Reproduction (HRP), whose research concerns people's sexual and reproductive health and lives,^[33] has an overall strategy to combat unsafe abortion that comprises four inter-related activities:^[32]

• to collate, synthesize and generate scientifically sound evidence on unsafe abortion prevalence and practices;
• to develop improved technologies and implement interventions to make abortion safer;
• to translate evidence into norms, tools and guidelines;
• and to assist in the development of programmes and policies that reduce unsafe abortion and improve access to safe abortion and high quality post-abortion care

During and after the ICPD, some interested parties attempted to interpret the term ‘reproductive health’ in the sense that it implies abortion as a means of family planning or, indeed, a right to abortion. These interpretations, however, do not reflect the consensus reached at the Conference. For the European Union, where legislation on abortion is certainly less restrictive than elsewhere, the Council Presidency has clearly stated that the Council’s commitment to promote ‘reproductive health’ did not include the promotion of abortion.^[34] Likewise, the European Commission, in response to a question from a member of the European Parliament, clarified:

The term ‘reproductive health’ was defined by the United Nations (UN) in 1994 at the Cairo International Conference on Population and Development. All Member States of the Union endorsed the Programme of Action adopted at Cairo. The Union has never adopted an alternative definition of ‘reproductive health’ to that given in the Programme of Action, which makes no reference to abortion.^[35]

With regard to the US, only a few days prior to the Cairo Conference, the head of the US delegation, Vice President Al Gore, had stated for the record:

Let us get a false issue off the table: the US does not seek to establish a new international right to abortion, and we do not believe that abortion should be encouraged as a method of family planning.^[36]

Some years later, the position of the US administration in this debate was reconfirmed by US Ambassador to the UN, Ellen Sauerbrey, when she stated at a meeting of the UN Commission on the Status of Women that:

Nongovernmental organizations are attempting to assert that Beijing in some way creates or contributes to the creation of an internationally recognized fundamental right to abortion.^[37]
There is no fundamental right to abortion. And yet it keeps coming up largely driven by NGOs trying to hijack the term and trying to make it into a definition.^[38]

See also

• Sexual intercourse#Health effects
• Abortion debate
• Demography
• List of bacterial vaginosis microbiota
• ICPD: International Conference on Population and Development
• POPLINE: World's largest reproductive health database
  • The INFO Project
• Reproductive justice
• Obstetric transition
• Organizations:
  • Association of Reproductive Health Professionals
  • Centre for Development and Population Activities
  • EngenderHealth
  • Guttmacher Institute
  • German Foundation for World Population
  • International Planned Parenthood Federation
  • Marie Stopes International
  • Reproductive Health Supplies Coalition
  • United Nations Population Fund

References

External links

• CDC Division of Reproductive Health
• WHO Reproductive health and research