(Dr. Mahmoud Fathalla)
ISSUES IN REPRODUCTIVE HEALTH
Health and being a woman
Being a woman has implications for health. Health needs of women can be broadly classified under four categories (Fathalla, 1997). First, women have specific health needs related to the sexual and reproductive function. Second, women have an elaborate reproductive system that is vulnerable to dysfunction or disease, even before it is put to function or after it has been put out of function. Third, women are subject to the same diseases of other body systems that can affect men. The disease patterns often differ from those of men because of genetic constitution, hormonal environment or gender-evolved lifestyle behavior. Diseases of other body systems or their treatments may interact with conditions of the reproductive system or function. Fourth, because women are women, they are subject to social diseases which impact on their physical, mental or social health. Examples include female genital mutilation, sexual abuse and domestic violence.
The reproductive system, in function, dysfunction and disease, plays a central role in women's health. This is different from the case with men. A major burden of the disease in females is related to their reproductive function and reproductive system, and the way society treats or mistreats them because of their gender. While more men die because of what one may call their "vices", women often suffer because of their nature-assigned physiological duty for the survival of the species, and the tasks related to it. In a study on investment in health, reported by the World Bank, ranking of the five main causes of the disease burden in young adults (15 to 44 years) in developing countries showed the following gender differential:
Females Males 1 Maternal HIV infection 2 Sexually-transmitted diseases Tuberculosis 3 Tuberculosis Motor vehicle injuries 4 HIV infection Homicide and violence 5 Depressive disorders War
The concept of reproductive health - women as sends and not means
Women, healthy women, need health care in order to be able to carry their sexual/ reproductive functions, and to carry them safely and successfully. During the second half of this century, there has been a vast expansion of health technologies and of health services to provide women with certain elements of reproductive health care. The services were not, however, without shortcomings.
Apart from inadequate allocation of resources, the major shortcoming was in the philosophy with which these services were provided. Women were considered as means in the process of reproduction and as targets in the process of fertility control. The services were not provided to women as ends in themselves. Women benefited from the process but were not at the center of the process.
The needs of women have been traditionally addressed within the concept of maternal and child health (MCH). The needs of the woman were submerged in the needs of the mother. MCH programs and services have played and continue to play an important role in promotive, preventive and curative health care of mothers and children. MCH services tend to focus on the healthy child as the successful outcome. While mothers care very much for this successful outcome because of the investment they make in the process of reproduction, this focus resulted in less emphasis being put on caring for the health risks to which mothers are liable during pregnancy and childbirth, and on putting in place the essential obstetric functions and facilities to deal with them. As a result, the tragedy of maternal mortality in developing countries has now reached dimensions that can no longer be ignored.
With all their benefits to the quality of life of women, family planning programs have left women with some genuine concerns as well as unmet needs (Fathalla, 1994). Women have more at stake in fertility control than anyone else. Contraceptives are meant to be used by women to empower themselves by maximizing their choices, and controlling their fertility, their sexuality, their health and thus their lives. Family planning, however, can be used and has been used by governments and others to control rather than to empower women. The family planning movement has been largely demographic driven. As far as policymakers are concerned, women were often objects and not subjects. Some governments were short-sighted, not to see that when women are given a real choice, and the information and means to implement their choice, they will make the most rational decision for themselves, for their communities and ultimately for the world at large.
With women as means and not ends, important health needs in the reproductive process have been left unmet. Infertility may not be a serious hazard as far as physical health is concerned, but can be a major cause of mental and social ill-health. It is not fair that society should provide care to reproducing women, but should neglect the suffering of those who are unable to conceive. Sexual intercourse exposes women to the risk of unwanted pregnancy. It exposes many women also to another serious or more serious risk, that of sexually-transmitted infections, including HIV infection. Family planning programs, with an exclusive demographic focus, cannot see the point of this important need for women.
The concept of MCH focusses special attention on women when and if they are reproducing, to ensure that society gets a healthy child, but often neglects their other reproduction-related health needs. Women's reproduction-related health needs are not limited to the reproductive years of their life. The girl child, the adolescent girl, and the mature adult and older woman have health needs related to their future or past reproductive function.
The societal attitude of looking at women as means and not ends is even more pervasive. Services offered to women often have something of a veterinary quality about it. Proponents of the education of girls cite the advantages that such education will have for the survival and health of the children, and the impact it will have on reducing birth rates. Nutrition of women is justified because of the needs of the foetus and the lactating infant. Even with the tragedy of maternal mortality, a justification put forward for investment in keeping mothers alive is that their survival is critical for the survival of the children.
The concept of reproductive health has recently emerged in response to the fragmentation of the existing services and their orientation. The broader concept of "reproductive health" offers a comprehensive, and integrated approach to the health needs related to reproduction. It puts women at the center of the process, as subjects and not objects, as ends and not means. It recognizes, respects and responds to the need of the woman behind the mother.
The reproductive health package
In the Constitution of the World Health Organization, health is defined as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. This definition, idealistic as it may look, is nowhere as relevant and applicable as in the area of reproductive health. A woman in the distress of carrying an unwanted pregnancy cannot be considered healthy simply because her blood pressure is not elevated and the foetus is showing a normal biophysical profile. In the context of this positive definition, reproductive health is a condition in which the reproductive process is accomplished in a state of complete physical, mental and social well-being and is not merely the absence of disease or disorders of the reproductive process.
Reproductive health implies that, apart from the absence of disease or infirmity, people have the ability to reproduce, to regulate their fertility and to practice and enjoy sexual relationships. It further implies that reproduction is carried to a successful outcome through infant and child survival, growth and healthy development. It finally implies that women can go safely through pregnancy and childbirth, that fertility regulation can be achieved without health hazards and that people are safe in having sex. (Fathalla, 1988).
Reproductive health is an integrated package (Fathalla, 1996). Women cannot be healthy if they have one element and miss another. Moreover, the various elements of reproductive health are strongly inter-related. Improvements of one element can result in potential improvements in other elements. Similarly, lack of improvement in one element can hinder progress in other elements.
Pelvic infection, for example, accounts for about one-third of all cases of infertility, worldwide, and for a much higher percentage in sub-Saharan Africa (WHO, 1987). The resultant infertility is also the most difficult to treat. The magnitude of the problem of infertility will not be ameliorated except by a combat of sexually transmitted diseases (STDs), by safer births that avoid postpartum infection, and by decreasing the need for or the resort to unsafe abortion practices.
Infant and child survival, growth and development cannot be improved without good maternity care. Proper planning of births, including adequate child spacing, is a basic ingredient of any child survival package. STDs, and in particular, HIV infection, unless adequately controlled, can impede further progress in child survival.
Fertility regulation is a major element in any safe motherhood strategy. It reduces the number of unwanted pregnancies, with a resultant decrease in the total exposure to the risk as well as a decrease in the number of unsafe abortions. Proper planning of births can also decrease the number of high risk pregnancies.
The reproductive health concept is not limited to mothers. Nor is it limited to women in the childbearing age. It recognizes the special health needs of adolescents related to their acquisition of the sexual and reproductive capacity before they have completed their social preparation for adult life. It recognizes that mature women, beyond the childbearing period, still have important health needs related to the reproductive system which they still carry and to the cessation of ovarian function. The concept also recognizes that the health of the adult builds on the health of the child, and that this is probably no more true than in the area of reproductive health. Finally, the concept of reproductive health is not limited to women. Men too have reproductive health needs, and responding to these needs of men is also important for women.
The unfair burden on women in reproductive health
Maternity is a unique privilege and a unique health burden for women. In some other aspects of reproductive health, where the responsibility is shared between men and women, the burden, for both biological and social reasons, falls heavily on women. This applies to the burden of sexually-transmitted diseases, fertility regulation and infertility.
According to a World Bank study quantifying the burden of disease, sexually-transmitted diseases (STDs) rank as the second major cause of the disease burden in young adult women in developing countries, accounting for 8.9% of the total disease burden in that age group (World Bank, 1993). Among males of the same age group, STDs are not among the first ten causes and account only for 1.5% of the disease burden.
For a mix of biological and social reasons, women are more likely to be infected, are less likely to seek care, are more difficult to diagnose, are at more risk for severe disease sequelae, and are more subject to social discrimination and consequences. The most effective method available for protection against STDs, the condom, is controlled by men. A simple and effective method of protection, that a woman can use without the need or necessity of her partner's cooperation, does not yet exist.
The unfair burden of fertility regulation
The modern contraceptive technology revolution provided women with reliable methods of birth control, which they can use independent of the necessity of cooperation of the male partner. This was at a price. They had to assume the inconveniences and risks involved. The role and responsibility of the male partner have receded when contraception was considered a woman's business. The percentage of current contraceptive use, worldwide, among couples in reproductive age in 1990 was estimated as follows (United Nations, 1994):
Female sterilization 17 percent Intrauterine device 12 Pill 8 Male sterilization 5 Condom 5 Other supply methods 2 Non-supply methods 8
Other supply methods include injectables, diaphragms, cervical caps and spermicides. Non-supply methods include periodic abstinence or rhythm, withdrawal, douche, total sexual abstinence if practiced for contraceptive reasons, folk methods and other methods not separately reported.
Women, therefore, assume a disproportionate responsibility for contraception in comparison to men. Not only do women have an undue burden of responsibility in fertility regulation, but the methods which women have available for use are those associated with potential health hazards. The importance of male participation and responsibility has become much more with the emergence of the Acquired Immune-Deficiency Syndrome (AIDS) pandemic and the increasing prevalence of sexually-transmitted infections, where the use of the condom is the only effective strategy for protection other than abstinence.
Reponsibility for infertility is commonly shared by the couple. Analysis of data compiled in a large WHO multinational study showed that a major factor in the female with no demonstrable cause in the male was diagnosed in only 12.8% of cases, and a major factor in the male with no demonstrable cause in the female was diagnosed in only 7.5% of cases (World Health Organization, 1987). The burden of infertility, however, for biological and social reasons, is unequally shared.
The infertility investigation of the female partner is much more elaborate and is associated with more inconvenience and risk. The burden of treatment also falls mostly on the female partner. Even for male infertility, the promise of successful management is now shifting to assisted conception technologies, where the female assumes the major burden.
The psychological and social burden of infertility in most societies is much heavier on the woman. A woman's status is often identified with her fertility, and failure to have children can be seen as a social disgrace or a cause for divorce. The suffering of the infertile woman can be very real.
"All countries should strive to make accessible through the primary health-care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015."
Programme of Action of the United Nations
(International Conference on Population and Development,
Cairo, 1994. Paragraph 7.6. (United Nations, 1994)
The challenge to make reproductive health care universally available, as demanded by the world government community in Cairo in 1994, has implications for resource allocation by countries and the international community, for organization of health services and for the health care profession.
The case for resources
Reproductive health has to compete with other health needs for scarce resources. There is a need to make priorities in the allocation of investments in health. Criteria for setting priorities include the magnitude of the health problem, its impact, as well as the availability of cost-effective interventions.
The burden of disease
In a joint major exercise of the World Health Organization and the World Bank, quantitative assessments were made of the global burden of different diseases, and the results were expressed in the terms of disability-adjusted life years (DALYs) lost as a result of the disease (World Bank, 1993).
Although in infancy and early childhood, girls and boys suffer from broadly similar health problems, striking sex differences emerge in adults. Women suffer disproportionately from their reproductive role. Although the burden of reproductive ill-health is almost entirely confined to the developing regions, it is so great that even worldwide, reproductive conditions make up three out of the ten leading causes of disease burden in women aged between 15 and 44 (Murray and Lopez,1996). In developing countries, five out of the ten leading causes of DALYs are related to reproductive ill-health, including the consequences of unsafe abortion and Chlamydia infection. Almost all of this loss of healthy life is avoidable.
The impact of reproductive health
The burden of a disease is primarily a function of its prevalence and its seriousness to the individual concerned. In the case of reproductive health, the impact is not limited to the individual directly concerned.
Inability of individuals and couples in developing countries to regulate and control their fertility because of lack of information and inadequacy of services, is not only affecting the health of the people immediately concerned and their families, but has implications for their societies and their countries, for global stability and for the balance between population and natural resources and between the human species and the environment.
Communicable diseases are important because they can affect other people too. Of all communicable diseases, STDs including HIV infection, are least amenable to control. Even attempting to erect national barriers will not stop them. People with other communicable diseases are less likely to travel than people with STDs, which are sometimes described as "air-borne" diseases, to indicate the importance of air travel in their trans-national spread.
The health of the child will impact on the health of the adult. Investment in reproductive health is an investment in our future.
Inequity in reproductive health
The Alma Ata Declaration in 1978 stated that: "The existing gross inequality in the health status of the people particularly between developed and developing countries, as well as within countries, is politically, socially and economically unacceptable, and is, therefore, of common concern to all countries." (World Health Organization, 1978)
There is no area of health in which inequity is as striking as in reproductive health. If we look at mortality differentials in the world, we find that while the crude death rate for the population is about ten percent more in the less developed than in the more developed regions, the infant mortality rate is almost six times higher, the child mortality rate is seven times higher, and the maternal mortality rate is fifteen times higher. In no area of public health are mortality differentials more marked than in the area of maternal mortality (Fathalla, 1993).
The availability of cost-effective interventions
The magnitude of the burden of disease, its impact and the glaring inequity are not enough to provide a rational basis for allocation of resources. The availability of cost-effective interventions has also to be considered. While the total disability-adjusted life years lost for the age group 15-44 years old was nearly the same for men and women, the percentage that can be substantially controlled with cost-effective interventions was estimated to be 43.9 percent for diseases of women, compared to 17.5 percent for diseases of men (World Bank, 1993).
It is for reasons of burden of disease, an impact that transcends national boundaries, as well as a deep concern about social injustice and inequity, together with the availability of cost-effective interventions that a major investment is justified in the field of reproductive health care.
A human rights dimension
The tragedy of maternal mortality in developing countries is not just a health problem; it should be recognized also as a human rights issue. The theme for World Health Day in 1998 was: "Pregnancy is Special; let's make it safe". When the World Health Assembly adopted this theme, it was setting a principle in health policy. Pregnancy is not a disease. Pregnancy is special. Pregnancy, a woman's privilege, is the means for survival of our species. Women have a right to safe motherhood, when they risk their life and health in order to give us life. Pregnancy should not compete for resources with disease conditions. Pregnancy is special.
The case for integration of services
The Oxford dictionary defines the word "integrate" as "complete (imperfect thing) by addition of parts; combine (parts) into a whole".
Reproductive health care should be an integrated package. There are ,however, two levels for integration. Services can be integrated at the level of policy, management and administration and/or at the level of service delivery.
A strong case can be made for integration of all reproductive health services at the level of policy, management and administration, to ensure that all these reproductive health needs receive attention and a relatively adequate allocation of resources.
At the level of service delivery, the approach should be pragmatic. Services should be integrated if integration makes their delivery more cost-effective. Different situations in countries should be judged on their own, taking into consideration some basic principles.
Service delivery will be more cost-effective either through better utilization, resulting in an increase of output, or cost savings, resulting in a decrease of inputs.
Better utilization of services can result when integration makes services more convenient and accessible to clients. It can also result when the demand on one service can increase or create demand for the other, e.g. the demand for child care may increase the demand for family planning.
Cost savings will be made when fixed costs are shared between different services. This will result if the same infra-structure can be used for the different services to be integrated, if the services can be provided by the same providers, and if enough excess capacity is available to meet the demands of the new service to be added.
Integration should be distinguished from "bundling" of services. The verb "bundle " (a common computer software jargon) is defined as "tie in, make up into, a bundle; throw confusedly in to any receptacle". When services are simply combined or joined together in one way or another, this is not necessarily integration. In such cases it may be more appropriately labelled as bundling. When services are combined or joined together as a strategy to provide a more complete package for services needed, this is integration.
The need for comprehensive health care should not translate to an all or none situation. Providing people with some elements of the service is better than providing no services. The best should not be made the enemy of the good. Services could be built up as resources become available and according to level of need and demand. Nor should integration result in dilution of available resources. Rather, it should result in more effective utilization of resources that are put together.
A tale of three family planning clinics
A woman visits a family planning clinic asking for an intra-uterine device (IUD). She has a reproductive tract infection.
In clinic 1, the infection is missed or ignored and the device is inserted. This is a poor quality family planning service.
In clinic 2, the infection is diagnosed. The woman is informed that she cannot have the IUD, and is given another contraceptive method. This may be considered a good quality family planning service, but is it?.
In clinic 3, the woman is provided with an alternative method of contraception but she is also provided with treatment for the reproductive tract infection or referred if treatment was not available. In addition, she is asked whether her last child has received the vaccinations on schedule. This is a reproductive health- oriented service.
Family planning services are not demographic posts. Family planning is a component of reproductive health care. Women are not "targets" for contraception, for which policymakers and administrators set "quota" for services to accomplish.
A woman-friendly reproductive Health service - ten propositions
For reproductive health services to be woman-friendly, they have to recognize and respond to the continuum of reproductive health care needs, they have to see the woman behind the mother, they have to see women as ends and not means, and they have to tailor their services according to women's needs and perceptions.
The following are ten propositions to make reproductive health services more "woman-friendly":
- MCH, family planning and other reproductive health services should be placed under one managerial responsibility, to ensure that all reproductive health needs are met, that all needs receive a relatively adequate allocation of resources, that services are adequately linked and coordinated, and where appropriate are integrated.
- Services should be organized to suit the convenience of users and not the convenience of providers. Reproductive health is about health needs of healthy people. Dealing with healthy people implies a change in the provider-patient relationship, from a giver- recipient relationship, to a more participatory type of health care. Counselling is the word for good reproductive health care.
- MCH should continue to integrate family planning services, as an essential component of pre-conceptional and postpartum reproductive health care, with counselling and informed choice as integral elements. This does not mean that family planning services should not be provided through other outlets as well. Women and men should have a broader choice, not only among contraceptive methods but also among providers and services. MCH service, as presently structured, are particularly inadequate as an outlet for adolescent services and services for men.
- Particularly in areas where STD prevalence is high, MCH services should consider integrating the provision of information, education, condoms, screening facilities, therapeutic procedures for lower reproductive tract infections and referral services. These should be provided for both prenatal patients and users of family planning.
- MCH services should be linked to the provision of essential obstetric functions at the first referral level. Without the back-up of and access to these essential functions, community based prenatal and delivery services will have much less impact on maker motherhood safer for women.
- The concept of reproductive health dictates that special attention should be given to the care of the girl child. This is not a female preference but to compensate for the social disadvantage of being a female in societies that discriminate against girls. It is also a recognition of the impact of the health and nutrition of the female child on the woman's future reproductive health.
- A woman-friendly service cannot bury its head in the sand, so as not to see unsafe abortion as a public health problem. It should respond in a way that is within the legal frame and within its capacity. There are a number of menu options for the service to select what it can afford and can deliver: expanding the effort for information, education and services for family planning; promoting the use of more effective methods; providing access to and information about emergency post-coital contraception; providing reliable free pregnancy testing to allow women with an unwanted pregnancy to take an early action if they so desire; introducing the menstrual regulation procedure ; providing humane services for victims of unsafe abortion; and, where not against the law, making available and accessible safe pregnancy termination services.
- A health education programme in a woman-friendly service, while focussing on the immediate needs of maternity and child care, should expand to cover other aspects of reproductive health care of women, including family planning, safe sex, and special needs of the mature woman related to the menopause and early detection of gynecologic malignancies. Breastfeeding should be promoted while recognizing the demand it puts on the woman to breastfeed. Women should be supported to breastfeed but should not be made to feel guilty if they cannot continue breastfeeding.
- Services should attend to the health care of all women, married or unmarried.
- Services should be sensitive to and aware of the social conditions in the community that adversely impact on women's health. These should be addressed in the health education programme. Violence against women, including female genital mutilation and rape, should be on the agenda. Reproductive health care providers have to interact with society. No society has ever been neutral about sexual and reproductive issues. Social values impact on women's health. No other health profession has to deal with emotionally charged health issues such as sexuality and abortion. We cannot ignore social issues in women's reproductive health even if we want to. A woman-friendly service does not play the ostrich and bury its head in the sands of biology and biomedical technology, and turn its back to the realities of social life.
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