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Reproductive health is life-long, beginning even before women and men attain sexual
maturity and continuing beyond a woman's child-bearing years.
Family planning has traditionally focused on only one aspect of reproductive healthcare
that is needed during a particular time of life -- providing safe, effective and
affordable contraception. In addition to family planning, reproductive healthcare
includes pregnancy and postpartum care, prevention and treatment of sexually transmitted
diseases, pregnancy termination, cancer screening and infertility counseling, among other
services. Related health concerns are numerous, including counseling about domestic
violence or gender inequality.
Different stages in a person's life require different reproductive health services.
Adolescents and unmarried women may not have access to effective contraceptive methods.
Pregnant women need dependable emergency care that is quickly available. Women with
reproductive tract infections and women who have terminated unwanted pregnancies may need
special counseling.
Poor reproductive health accounts for a substantial portion of all deaths among women ages
15 to 49 worldwide.1 These deaths arise from complications
during pregnancy or childbirth, from reproductive tract infections, and unsafe abortion.
Domestic violence and sexual abuse contribute to these deaths, as well as to many injuries
and illnesses.
"We continue to get more data showing women's reproductive health problems are far
more prevalent than we previously thought," says Dr. Karen Hardee, a senior research
associate at FHI. Some of these conditions can be improved by expanding family planning
services into other areas of reproductive healthcare, she says, although careful planning
and evaluation are necessary to determine which additional services would be feasible and
worthwhile.
Limited resources
Expanding reproductive health services can be effective but also raises questions about
how limited resources should be spent. Some experts maintain that many reproductive
illnesses and deaths could be prevented or treated using technology currently available in
most countries.2 In some countries, maternal health
investments of US $1.50 a year per person of the total population can reduce maternal
mortality by as much as 65 percent, according to Anne Tinker at the World Bank.3
A substantial number of family planning programs have already implemented services that go
beyond contraceptive services. In 1993, the U.S. Agency for International Development
surveyed 50 countries on reproductive health activities either ongoing or planned to begin
by 1995. The survey divided reproductive health into four categories: family planning or
safe regulation of fertility; maternal health and nutrition; protection from STDs; and
reproductive rights. More than half of the agencies surveyed had already integrated some
form of STD services with family planning, and one-fourth were providing services from all
four categories.4
Combining services may improve efficiency by reducing duplication and minimizing the
number of workers and facilities needed.5 In an evaluation by
the Population Council, programs in Tegucigalpa, Honduras and Lima, Peru that combined
postpartum services with family planning achieved a higher contraceptive prevalence and
cost savings. In an experimental study in Lima, women offered contraception before
hospital discharge were substantially more likely to be using contraception six months
postpartum, compared to women who did not receive any family planning after childbirth.
Because in-patient IUD insertion in Lima cost $9.38 per woman compared to $24.16 for
out-patient insertion, implementing postpartum family planning at Peruvian Social Security
Institute (IPSS) hospitals is expected to save about 5 percent of IPSS's annual family
planning costs.6
However, integrating new health services into a family planning program may enhance one
component of healthcare at the expense of another. Primary healthcare clinics in many
countries already have many tasks to meet, says FHI's Dr. Nancy Williamson, who has
written extensively on the integration of family planning and STD services.
"A lot of people have good will and want to cover a larger reproductive health need,
but from a family planning perspective the question is, 'How can we find compatible
activities without diluting family planning?'" asks Dr. Williamson, who directed the
evaluation of a large maternal and child health and family planning integration project in
the Philippines. "More thought needs to be given on how to integrate the activities
for a worker or a client."
There are many reproductive health services that could be added to family planning
services. Two of the most widely studied service categories include maternal healthcare
and STD prevention or treatment.
STD prevention
Family planning programs may be an appropriate place to provide STD prevention and
treatment because many of the functions overlap. Counseling on sexual activity (including
abstinence) and providing barrier contraceptives, which help protect against STDs, are
examples of related services, says Dr. Ward Cates, FHI's corporate director of medical
affairs.
Having an STD increases a person's risk for HIV infection and transmission. STDs also
contribute to reproductive tract problems in women, can harm unborn fetuses, and increase
a woman's chances of developing cervical cancer.7 Most STDs,
including syphilis, genital herpes, chancroid, genital warts, bacterial vaginosis,
trichomoniasis, chlamydia and gonorrhea, increase a woman's risk for illness and death
during pregnancy and childbirth. Swelling and infection in the upper reproductive tract
can cause ectopic pregnancy, resulting in hemorrhage.
Family planning providers can prevent some of these infections through screening, condom
distribution, couples counseling, maintaining hygienic facilities, and being sure that
contraceptive services or procedures do not spread or aggravate infections.
Combining basic STD screening and some of the more inexpensive treatments with family
planning may be easy to do and worthwhile, says Dr. Williamson. "There's fairly wide
agreement among scientists that if a family planning program's clientele has an STD
problem, the program should try to do something about it." Health providers should
consider developing a simple way to evaluate their clients' STD risk in order to determine
how much to spend on screening for a particular disease.8
Because STDs are frequently asymptomatic in women, inexpensive screening may not be
completely successful. Dependable diagnostic procedures are often costly and may require
laboratories or expensive equipment.
One inexpensive method for assessing risk is interviewing clients about their symptoms,
also called a "syndrome-based approach." However, in addition to a lack of
symptoms in some clients, cultural values may discourage talking openly about intimate
relationships and risk behaviors. In Rio de Janeiro, Brazil, FHI researchers were able to
encourage frank discussions of STD risk and sexual relations at family planning clinics by
using a cartoon soap opera with clients who met in small groups. In private counseling
later, the number of clients who were willing to discuss their partners' infidelity and to
identify themselves as being at risk for HIV infection increased dramatically compared
with their willingness prior to the group sessions, says Dr. Patsy Bailey, public health
specialist at FHI's Maternal and Neonatal Health Center. "By talking about it in a
group, they allowed themselves to admit it," says Dr. Bailey. "There may have
been less denial."
Another question concerning the efficacy of combining STD services with family planning
involves the type of clients family planners typically serve. To be most effective in the
fight against STDs, health workers may have to target high-risk populations, such as
prostitutes and other people with multiple partners. Treating an STD in one high-risk
person may avoid transmissions to many others. Family planning clients, however, typically
are married women with only one partner. "Nevertheless, family planning providers
should not assume their traditional clients do not have a problem," says Dr. Bailey.
"The number of women infected with HIV has been increasing, even among groups you
wouldn't normally think would be at risk. It seems to justify an intervention."
FHI's Dr. Williamson urges family planning providers to assess the STD risk of clients,
even if it is only to ask clients about their risk of infection. "I don't see how you
can recommend a contraceptive method if you don't know a client's STD risk," she
says. "Yet it isn't being done often enough. It isn't going to be perfect, you have
to tailor the questions to each setting, but it doesn't cost anything to do."
Clients should consider their risk of STDs when choosing a method. Family planning
programs tend to encourage contraceptives that will be the most effective at preventing
pregnancy. Preventing STDs, however, may require the use of latex condoms, which are
typically less effective at preventing pregnancy than longer-acting methods since some
people do not use barrier methods consistently and correctly. One option is use of
"dual methods," using a barrier method to guard against STDs and another method
as a contraceptive, such as injectables, the pill, or Norplant.
Maternal health
Family planning plays a major role in preventing maternal mortality and morbidity.
"The biggest dent you can make in maternal morbidity is not getting pregnant,"
says Dr. Judith Fortney, director of FHI's Maternal and Neonatal Health Center. Although
there are risks associated with any contraceptive method, these risks are substantially
lower than the health risks associated with pregnancy and childbirth. Family planning can
also reduce health risks associated with closely spaced pregnancies, high-risk births, and
unsafe abortion, concluded a National Academy of Sciences (NAS) panel.9
Maternal mortality declines when women have better access to safe contraception, according
to Dr. Fortney. For example, maternal mortality fell by one-third in a rural area of
Bangladesh following a community project that increased contraceptive prevalence to 50
percent, compared with 23 percent in a control area.10 Family
planning programs may also be appropriate places to counsel women on prenatal care and to
encourage breastfeeding.
Although family planning providers rarely see women when they are pregnant or in the midst
of childbirth, they could easily give information about prenatal care, pregnancy
complications and encourage breastfeeding. They could also provide basic prenatal
services, such as iron and iodine supplements, and tetanus toxoid and malaria prophylaxis
in infested areas, says Dr. Fortney.
A MotherCare program in Cochabamba, Bolivia increased women's awareness of danger signs in
pregnancy by providing such basic information -- a relatively inexpensive service.11 "Forget about weighing patients, forget about nutrition.
Every woman knows she should eat more, and she would if she could," says Dr. Fortney.
"But if you tell clients symptoms to look out for -- indicators of pregnancy
complications, when you really have to go to a hospital, where to go, how to get
transportation -- then you'll really be doing something to reduce maternal
mortality."
Family planning providers may be able to help pregnant patients plan hospital
transportation in advance, she says. A woman's ability to reach obstetric care often
depends on help from the community. Since most life-threatening complications occur during
labor and delivery, every pregnant women needs rapid access to emergency obstetric care.
The majority of maternal deaths and much of chronic morbidity resulting from childbirth
are due to lack of timely medical help for pregnancy complications.12
After a woman has given birth, family planning providers can play an important role in
counseling about birth spacing and contraceptives. For example, many breastfeeding mothers
may not know about the natural contraceptive benefits from breastfeeding, also called the
Lactational Amenorrhea Method (LAM). LAM is highly effective during the first six months
postpartum as long as a woman has not resumed menstruation and is fully or nearly fully
breastfeeding.
Priorities
There are many ways to define reproductive health. Different definitions and priorities
are being proposed by women's health advocates and family planning organizations around
the globe.
One approach, articulated by FHI's Dr. Hardee and Kathryn Yount of Johns Hopkins
University School of Hygiene and Public Health, uses the consensus statement from the
United Nation's 1994 International Conference on Population and Development to identify
possible services. Good reproductive health, according to the statement, should include
freedom from the risk of sexual diseases; the right to regulate one's own fertility with
full knowledge of contraceptive choices; and the ability to control sexuality without
being discriminated against because of age, marital status, income, or similar
considerations.13
Achieving these goals will require a wise use of resources, which may include ways to
integrate different reproductive services. For example, family planning programs and other
reproductive health projects may be able to share certain services, such as maintaining a
central file of patient records. The policies and administrative structure of each country
will play a role in determining how different health services are combined.
Client needs and the culture of each community and country should be considered. "To
look at reproductive health means looking at all aspects of people's lives," says Dr.
Hardee. "Certainly, you need to prioritize. But we think that's something you have to
do at a country level."
Another effort to define reproductive health and prioritize goals is being made by NAS, a
U.S.-based scientific society. "We don't think we're going to come up with
instructions, or a recipe for action," says John Haaga, director of the NAS Committee
on Population. "But a lot can be done to clarify priorities that should bring us
closer to some answers." In 1996, a NAS study panel may recommend a priority list of
reproductive healthcare services that could be used in many settings, he says.
-- Sarah Keller
Footnotes
- Starrs A. Preventing the Tragedy of Maternal Deaths:
A Report on the International Safe Motherhood Conference. Nairobi: World Health
Organization, 1987. Jacobson JL. Worldwatch Paper 102: Women's Reproductive Health: The
Silent Emergency. (Washington: Worldwatch Institute, 1991) 5.
- Jacobson.
- Tinker A. Safe motherhood: How much does it cost?
Unpublished paper. World Bank, 1990.
- Pillsbury B, Maynard-Tucker G. USAID Reproductive
Health Baseline Survey: A Survey of Projects and Activities Implemented and Planned by
USAID Missions and Cooperating Agencies. Washington: USAID, 1994.
- Hardee K, Yount K. From Rhetoric to Reality:
Delivering Reproductive Health Promises through Integrated Services. Women's Studies
Project Working Paper No. 2. Durham: Family Health International, 1995.
- Foreit K, Foreit J, Lagos G. Effectiveness and
cost-effectiveness of post-partum IUD insertion in Lima, Peru. Int Fam Plann Persp
1993; 19(1): 19.
- Family Health International. Proceedings of
Understanding STDs and the Public Health Approaches to Their Control: The Appropriate Role
of Family Planning Programs. (Durham: FHI, 1994) 2.
- FHI, 4.
- DeVanzo J, Parnell A, Foege W. Health consequences of
contraceptive use and reproductive patterns. Journ Amer Med Assn 1991; 265(20):
2692-96.
- Fauveau V. Matlab maternity care program. Unpublished
paper. World Bank, 1991. 29.
- Pillsbury, D-1.
- World Health Organization Maternal Health and Safe
Motherhood Programme Division of Family Health. Care of Mother and Baby at the Health
Centre: A Practical Guide. (Geneva: WHO, 1994) 9.
- International Conference on Population and Development. Programme
of Action of the International Conference on Population and Development. New York:
United Nations, 1994.
For more information, visit Family Health International's Website at www.fhi.org
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