CHAPTER 2:
Rights for Sexual and
Reproductive Health

The crucial change—what in effect made it possible to discuss reproductive roles in terms of rights—was introduced by modern contraception: the possibility of women themselves controlling the timing and frequency of pregnancy. Contraceptive prevalence—the proportion of couples using some form of contraceptive method—has risen from 15 per cent in 1960, to nearly 60 per cent across the developing world, and to near-universality elsewhere. For a growing number of women, contraception is part of everyday life.

Relations between men and women—as individuals, as family members and members of a community—are part of a complex structure of social practices, values, power relationships and negotiated understandings. Modern contraception, by introducing the possibility that women can make their own decisions on family size and spacing, has permanently altered the structure. One result is a vigorous debate in all countries about women's and men's reproductive roles and rights.

While the right to health is recognized almost universally, women especially carry a heavy and largely avoidable burden of poor health related to reproduction and sexuality. The first section of this chapter addresses a number of the major causes and some of the solutions.

The right to health, the right to the benefits of scientific progress and the right to determine the number and spacing of one's children, among others, imply a right to reproductive health, and hence to reproductive health services that respect and promote the rights of clients. This means that services must respond to clients' needs and desires, and facilitate individual choice and informed consent.

The second section of this chapter discusses sexual and reproductive health services and related issues.

Poor Women, Poor Health

Malnutrition/Anaemia

Malnutrition contributes more than any other factor to disease and injury worldwide. It contributed to 5.9 million deaths in 1990 and played a role in fully 15.9 per cent of all morbidity (illness).¹ Most of the people who died were in Africa and south Asia, and many were in the first years of life when children are especially vulnerable. Poverty was the main underlying cause, but a disproportionate number were female. In many families girls and women are last in line for food.

Malnutrition and associated health problems among young girls are far more common than they need be, even in poor families. Malnutrition for girls in early life contributes to health problems later on. It contributes to anaemia, a risk which intensifies after the start of menstruation. In developing countries, iron-deficiency anaemia is the third leading cause of disease for women between ages 15 and 44. It contributes 4 per cent of the total disease burden, exceeding the contribution of war; in industrialized countries it contributes about 1.5 per cent, only slightly less than traffic accidents.

Malnutrition and anaemia contribute to many of the problems found in pregnancy and delivery and play a part in many maternal deaths.

Complications of Pregnancy

More than 585,000 women die each year from causes related to pregnancy. For each death, at least 13 women suffer from a less serious threat to their health. In some countries, where emergency care is more accessible and fewer women die, over 3,000 women may suffer ill-health from pregnancy- related causes for each maternal death.² Complications of pregnancy are found everywhere, but nearly all maternal deaths are in developing countries: an African woman is 500 times more likely to die of pregnancy-related causes than her counterpart in one of the Scandinavian countries.

Obstructed labour, haemorrhage and postpartum infection (maternal sepsis) are among the major causes of maternal mortality. Obstructed labour and sepsis are the sixth and eighth leading causes of disease in developing countries, accounting together for over 6 per cent of the total burden. In developed countries they are 12th and 14th and account for about 2 per cent.

Obstructed labour, where the birth canal is blocked, is often the result of starting childbearing too young, before the pelvis has developed sufficiently, or of long-term malnutrition which has stunted physical development. The outcome can be tragic for both mother and child, especially in the absence of skilled emergency care, and especially if the mother is weakened by anaemia. Obstructed labour subjects the young mother to hours of unbearable pain, it can easily lead to haemorrhage and infection, and sometimes leaves the mother permanently crippled.

Transport for women in labour is particularly difficult and life-threatening. In Ananthapur District in India nearly 70 per cent of women arriving at hospitals during a complicated pregnancy travel by public bus and 19 per cent by animal-drawn carts. One study in China found that 15 per cent of recorded maternal deaths occurred on the way to hospital.³ Men often control the cash needed for transport and may not understand the risks of childbirth and the need for care, except in dire emergency. Still less do they appreciate the importance of prenatal and post-natal care for the health of their wives.



Better overall health would reduce this burden of death and morbidity. Better care would reduce it dramatically. The first need is to identify the 10 per cent of pregnancies at risk. Prenatal examination and observation could identify most of these. The second is to train attendants in sterile procedures and obstetric first aid, and the third is prompt and efficient referral to emergency obstetric care. The underlying issue is the need to give priority to women's health.

Sexually Transmitted Diseases

There are an estimated 333 million new cases of sexually transmitted diseases (STDs) every year. Worldwide, the disease burden of STDs in women is more than five times that of men. STDs cause the second highest burden of disease for women aged 15-44 in developing countries, after maternal mortality and morbidity. If human immunodeficiency virus (HIV) infection is included, they account for nearly 15 per cent of all health lost to people in this key productive age range. This is probably an under-estimate, since little attention has been paid to STDs until recently. Many sufferers are infected by more than one disease. Almost two thirds of cases of infertility are attributable to STDs.⁴

STDs are most frequent in young people aged 15-24. Fully 50 per cent of HIV infections are to people in this age group; many of the sufferers contracted the disease before they were 20. In all countries, young women are the group facing the highest risk of HIV infection through heterosexual contact.

In the United States, the highest incidence of gonorrhoea in women is among 15-19 year-olds; among males, 15-19 year-olds have the second highest incidence.⁵

Young adults are particularly vulnerable to STDs and most know very little about them. Young people who become sexually active early are more likely to change sexual partners and risk greater exposure to STDs. Millions of adolescents live or work on the streets; many turn to selling sex to make a living. Young women especially may be forced into sex or have little power to negotiate condom use with older sexual partners. Young people may be more reluctant to seek help from health services, because they do not know they have a disease, because they are embarrassed or ashamed, or because they cannot afford services.⁶ For reasons of policy or because care providers are embarrassed, adolescents may not be given information even when they seek care.



Beyond these social concerns, there are anatomical considerations. The cervical mucus of young women differs from that of older women, making them more susceptible to gonorrhoeal and chlamydial infection and to the human papilloma virus.⁷

Women's susceptibility to STDs is based on both biological and social realities. Women's reproductive systems expose a greater surface area of sensitive tissues to a greater variety of pathogens during intercourse. When delicate mucosal tissue is torn or damaged the risk of transmission of STDs, including HIV/AIDS, is greatly increased. In many societies sexual practices (including a preference for "dry sex" which increases friction and male sexual pleasure) can increase the likelihood of injury to women. Other practices, including female genital mutilation, can also increase the likelihood of recurrent genital tract infections and other disorders which increase the risk of STD infection.

The impact of STDs on women is greater than on men. STDs cause pregnancy- related complications, sepsis, spontaneous abortions, premature birth, stillbirth and congenital infections.⁸ Of all maternal deaths, 1-5 per cent are due to ectopic (tubal) pregnancies mostly attributable to sexually transmitted diseases. Thirty-five per cent of postpartum morbidity is attributed to sexually transmitted diseases. Of all gynaecological admissions to hospitals, 17- 40 per cent are due to pelvic inflammatory disease which is mostly due to STDs. The human papilloma virus is a cause of cervical cancer, the second most common cancer in the world, with almost half a million new cases each year.

Reproductive tract infections (RTIs) affect 50 to 60 per cent of women in some developing countries, most of whom could be treated with antibiotics. Most sexually transmitted diseases are RTIs, although some STDs, such as syphilis, hepatitis B and HIV/AIDS also affect other parts of the body. One million people die each year as a result of reproductive tract infections, not including deaths from HIV/AIDS.⁹

A wide range of reproductive tract disorders can result from exposure to STDs, including varieties of cervical cancer. Often they do not immediately show themselves, but if untreated they can lead to more serious threats to health.

An STD or reproductive tract disorder increases the chance that any single sexual encounter will transmit the HIV virus. In societies where STDs are widespread, and where people have many sexual partners, the risk of HIV infection is dramatically increased.

Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS)

There are currently 22.6 million people living with HIV/AIDS. Since the start of the pandemic, 8.4 million people have progressed from HIV infection to symptomatic AIDS and 6.4 million of them have died. According to UNAIDS¹⁰ estimates there were over 3.1 million new HIV infections during 1996. This amounts to more than 8,500 a day—7,500 adults and 1,000 children. HIV/AIDS-associated deaths in 1996 numbered 1.5 million, including 470,000 women and 350,000 children below age five.



HIV/AIDS is still spreading rapidly in many countries. The epidemic is becoming well established in several large countries in Asia. The largest numbers of new cases have been observed in South Asia, especially India. The disease is now found in areas with previously low levels of infection (including the former Soviet Union).

Approximately 42 per cent of the 21.8 million adults living with HIV/AIDS are women, and the proportion is growing. The majority of newly infected adults are between ages 15 and 24. Worldwide, of every 100 HIV infections in adults, 75 to 85 have been transmitted through unprotected sexual intercourse (i.e., without a condom). Heterosexual intercourse accounts for more than 70 per cent of all adult HIV infections to date. Transfusion of contaminated blood accounts for 3-5 per cent of infections. The sharing of HIV-infected injection equipment by drug users accounts for 5-10 per cent of adult infections. This proportion is growing and is, in many parts of the world, the dominant mode of transmission. The remaining 5-10 per cent of infections have been transmitted through homosexual intercourse.¹¹

Mother-to-child transmission accounts for more than 90 per cent of all infections in infants and children. HIV/AIDS prevalence among children is almost 35 times higher in the developing world than in the industrialized world. About 25 to 35 per cent of infants born of HIV-infected mothers become infected before or during birth, or through breastfeeding. Estimates of the number of children who have been infected during the pandemic vary. HIV infection progresses more rapidly to AIDS in children and survival is short. About one quarter of all AIDS-related deaths have been to children infected by vertical transmission from their mothers. Over 85 per cent of children infected by mother-to-child transmission have been in sub-Saharan Africa.



Social and Behavioural Issues in STD Transmission

Preventing the spread of sexually transmitted diseases involves a variety of public health measures. Fuelling the tragedy are a variety of beliefs and practices about sexuality, social identity and power relationships. Transmission of these diseases is generally easier from male to female than from female to male. In the case of HIV/AIDS, a woman is many times more likely to be infected by intercourse with a man than a woman is likely to pass on the disease to her partner.¹² Men's concern about contracting HIV has led to increasing sexual exploitation of young women, who are presumed less likely to be infected. Some men also choose to believe that sex with a virgin can cure AIDS.

Economic conditions and gender inequities also contribute to women's risks. Men who migrate to cities for work and are separated from their families create a demand for sexual services. Men who refuse to use condoms as part of commercial sex help spread STDs and carry infections back to their wives. Cultural expectations of female passivity and subservience to men, low control over the sexual behaviour of male partners and inability to negotiate condom use contribute to the susceptibility of women, whether as wives or as sex workers. They may have no symptoms of infection (half of infected women are asymptomatic), or may not recognize the symptoms they have. They may not seek care for fear of being rejected by health care providers or labelled as a prostitute in the community; or there may simply be no services available.

Little regard is paid to women's wishes and concerns regarding sex. Wives are often considered the sexual property of their husbands and must comply with his wishes or risk disapproval. The penalty of refusal can be divorce, violence or worse. Even a woman whose regular partner has relationships with other women may feel unable to ask him to use a condom with her. At the same time, poverty may impel women to seek sexual partners outside marriage as a means to find a mate or to provide an income. Such women are at greater risk of disease, maltreatment and social sanction.¹³

Abortion

Abortion is legal under some circumstances in nearly all countries of the world: 98 per cent of countries, with 96 per cent of the world's population, recognize a threat to the mother's life as a legal basis for stopping a pregnancy. An estimated 25 million abortions are performed each year in countries where it is legal.

Overall, 62 per cent of countries with 75 per cent of global population make some provision for preservation of the physical health of the woman as a basis for legal abortion, though definitions of the risks to health diverge sharply. Protection of women's health is a legal ground for abortion in 89 per cent of industrialized countries but in only 52 per cent of developing countries. Whatever the legal status, wide differences in individual attitudes to abortion can be found in all countries.



While legality does not guarantee safety, a higher proportion of illegal abortions are performed under unsafe conditions. Legal abortions may be unsafe when access is restricted by bureaucracy (as in the former Soviet Union), where services are poor or not available, or where medical staff refuse to perform the operation.¹⁵



Women may seek to end a pregnancy resulting from unwanted sex, lack of contraceptive information and services, unsuccessful contraception or because of a change of circumstances since conception. Direct estimates of national levels of abortion are difficult to obtain, except where the procedure is legal and reporting systems function well. Estimates are often based on information about the number of women hospitalized from abortion-related causes, adjusted for access to and availability of safe abortions. In Latin America, for example, data indicate that about one in five clandestine abortions leads to complications and subsequent hospitalization.¹⁶

The impact of abortion on fertility is difficult to assess. In 33 countries studied, abortion was found to be widely used to control fertility.¹⁷ Both contraceptive use and abortion respond to the emerging desire of women and men for smaller families, but increased availability and use of contraception reduce the impact of abortion. Similar studies in more countries will help clarify how these changes work.¹⁸

Many, though not all, women who resort to abortion would use contraception if given a choice. In Nigeria, only 10 per cent of women hospitalized for abortion complications had ever used contraception, but 45 per cent said they wanted to do so. In Bolivia, only 7 per cent of such women had ever used contraception yet 77 per cent said that they wanted to do so.¹⁹

Where abortion is safe and widely available, and other reproductive health services are in place, rates of abortion tend to be low.

The simple conclusion is: better contraceptive services for all people will reduce abortion.

Female Genital Mutilation

Female genital mutilation (FGM), which is sometimes locally referred to as "female circumcision," "Pharaonic circumcision"; "Sunna circumcision," or other local terms,²⁰ is a traditional practice with horrific effects on the health of girls and women, though health consequences vary in gravity according to the severity of the procedure.

FGM has been condemned by the ICPD and FWCW and in a joint WHO/UNICEF/UNFPA statement²¹ as a violation of human rights including the right to the highest attainable level of physical and mental health, and the right to security of the person.²²





Female genital mutilation, according to the WHO definition,²³ comprises all procedures involving partial or total removal of the external female genitalia or other injury to female genital organs. A WHO classification recognizes three degrees of severity of FGM: (I) the removal of the surrounding tissue (prepuce or clitoral hood) and sometimes all or part of the clitoris, (II) removal of the clitoris and part or all of the labia minora (inner vaginal lips), and (III) (referred to as infibulation) removal of the clitoris, some or all of the labia minora and incisions on the labia majora (outer vaginal lips) to create raw surfaces which are either stitched together or kept together until they seal to cover the urethra and most of the vaginal opening. Another category includes, among other practices covered by the primary definition of FGM: piercing or cutting of the clitoris and/or labia; scraping of tissue around the vaginal orifice and/or cutting of the vagina; and introduction of substances or herbs into the vagina with the aim of tightening it.

It is estimated that over 120 million living women have undergone some form of genital mutilation and at least two million girls per year are at risk of mutilation. It is practised by many ethnic groups, from the east to the west coast of Africa, in southern parts of the Arabian peninsula, along the Persian Gulf and among some migrants from these areas in Europe, Australia and North America. It has also been reported in some minority groups in India, Malaysia and Indonesia. Experts estimate that about 80 per cent of affected women have undergone removal of the clitoris and labia minora. Infibulation is widespread in Somalia, Northern Sudan and Djibouti where it constitutes as much as 80 to 90 per cent of such practices²⁴ and has a correspondingly higher rate of complications.

FGM is usually carried out by traditional practitioners using cutting tools ranging from pieces of glass to scalpels or special knives which are often reused without sterilization. Anaesthetics and antiseptics are not generally used and various substances are rubbed on the wounds to stop bleeding. Unintended damage is often caused by septic conditions or because of the struggling of the girls or women during the procedure. It is increasingly performed by trained medical personnel on the assumption that this is more hygienic. Medical participation in FGM is, however, strongly condemned by WHO.²⁵

The age at which the procedure is performed varies depending on the ethnic group and location. It is sometimes performed on babies, more commonly on girls between ages 4 and 10, but also in adolescence, or as late as the time of marriage or during the first pregnancy. In most regions where it is practised, men may refuse to marry a woman who has not undergone FGM. Adult women are under pressure to submit to it in order to ensure the status which marriage and childbearing confer and to demonstrate solidarity with family and community. Younger women and girls have no choice at all.

The international move to eliminate FGM has the support of women's and professional medical groups in the countries affected, of governments, and of the international community. The International Conference on Population and Development agreed that FGM was a violation of human rights and a lifelong threat to women's health, and urged governments to prohibit it.

Some observers see links with the broader social and economic picture. They point out that worsening poverty in Africa has driven communities to identify "modernization" as the cause of their problems, and thus to oppose any change, including changes in traditional practices such as FGM. An extreme view identifies opposition to FGM as a form of cultural imperialism and minimizes the reproductive and sexual burdens which it imposes on women.²⁶

The practice has deep roots: nearly 90 per cent of the women in a study in the Sudan²⁷ had themselves gone through the procedure; nearly three quarters had undergone infibulation. Similarly, close to 90 per cent of the women surveyed had either had their daughters undergo FGM or planned to have all their daughters undergo it. Of these women, only slightly over one fifth favour less severe procedures (type I). Women with more education were more likely to oppose the procedure for their daughters. The husband's education also affected the woman's attitudes; but the woman's own level of education was the more important predictor.

Several NGOs are working to raise awareness about the need to eliminate FGM. One, the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, has established national committees in 23 countries. Founded in 1984, the Committee has sponsored workshops, seminars, training for nurses and traditional birth attendants, information campaigns, and research and surveys on various aspects of traditional practices and their influence on the health of women and children. The Kenyan women's organization Maendeleo ya Wanawake has developed community-based programmes to reduce the incidence of FGM. In Uganda, the Reproductive, Educative and Community Health programme has undertaken a culturally sensitive campaign to show that practices can change without compromising values.



Beliefs and practices regarding FGM seem to show a desire to control women's sexual experience and reinforce established gender roles. They support a priority for male over female sexual satisfaction (often at reproductive risk to women) and give evidence of profound ambivalence among men regarding the sexual needs and concerns of women.

Successful efforts to eliminate FGM call for considerable sensitivity, because of the intensity with which cultural beliefs are held. They must secure the cooperation and understanding of leaders of the community, including women who have undergone the procedure themselves. FGM is one of many cultural practices, some of which are beneficial to health, including premarital abstinence, prolonged breastfeeding, and postpartum abstinence and other means of extending birth intervals. Loyalty to tradition and group solidarity can reinforce practices which directly benefit families and the community, while at the same time confronting those which damage the integrity and diminish the personality of the individual woman.

Eliminating FGM will require²⁸ :

—enforcement of existing laws prohibiting the practice

—legal change and advocacy

—grassroots community education, especially directed at men

—training and coordination with health care providers

—involvement of community leaders

—work with immigrant and refugee communities

—culturally sensitive research It will also require outright condemnation of FGM by leaders at all levels.

Reproductive Health Services

Despite considerable progress over the last two decades, the right to reproductive health remains far from realization in most countries. International acceptance of the concept of reproductive rights at the International Conference on Population and Development and Fourth World Conference on Women has served to illustrate the present position.

The Life Cycle Approach

Reproductive health is a lifetime concern for both women and men. Sex-selective abortion has been condemned but is still practised as a result of boy preference, which also accounts for discrimination against girl infants and children. Issues of education and appropriate health care arise in childhood and adolescence, and concerns continue into the reproductive years when issues are family planning, STDs and reproductive tract infections, adequate nutrition and care in pregnancy, and the social status of women; and continue to old age, with concern for heart disease, osteoporosis as a result of oestrogen deficiency and the social role of older women in passing on information and setting rules for behaviour. Male concerns arise in boyhood, when attitudes towards gender and sexual relations are often set for life, and continue into old age when men are often the elders and rule-givers. Men need early socialization in concepts of sexual responsibility to promote healthy sexual and family formation behaviour; women need protection from discrimination and positive moves towards equality. Both need reproductive health care appropriate to their age and situation.

Women's routine health care has often been available only through maternal and child health services. These services have generally put the emphasis on child health, and addressed only a restricted set of women's health needs. Most have completely ignored young, unmarried women, women suffering from RTIs and infertility, and women past childbearing age. Women's long-term reproductive health problems often stem from lack of care in infancy, childhood and adolescence. For example, boys are more likely to be hospitalized for treatment of protein-energy malnutrition, though it is more prevalent among girls, who may have less access to whatever nutritious food is available.

Adolescents have special needs related to reproductive health. In particular, they should have the information and services they need for responsible exercise of their reproductive rights. Parents equally have roles and responsibilities, notably that they should do no harm to children's reproductive and sexual health and potential.

Integrated Health Programmes: Treating the Person in Context

Access to basic health services has improved over the past two decades. Even during the economic stagnation of the 1980s, improvements were observed in many countries in Africa, the Americas and Asia.²⁹ The emphasis on primary health care agreed at the Alma Ata "Health for All" Conference of 1978, and now incorporated in the ICPD Programme of Action, has led to longer and healthier lives for many of the world's peoples. Male and female life expectancies in less developed regions have increased from 55.7 and 57.8, respectively, in the late 1970s to 62.1 and 65.2 today.³⁰



Guaranteeing the right to health in developing countries requires more than ordinary ingenuity, however, matching available resources with extensive and growing needs.³¹ Budgets for primary health care have not kept pace with requirements. Because of population growth, per capita allocations from government programmes have decreased in the last decade.³² Budgets have been further constrained in the poorest countries by the requirements of "structural adjustment" programmes aimed at reducing public-sector spending. This has led to recent declines in life expectancy in some affected states, particularly in sub-Saharan Africa. The availability and quality of health services in countries in economic transition have deteriorated as well with similar effects on life expectancy. The impact of these adjustments has been felt most keenly by the poor, and especially women and children.

Shrinking budgets at a time of growing demand have led to a variety of expedients to reduce the cost of health programmes for the public sector while maintaining quality. The long-term sustainability of health programmes requires a balanced mix of funding sources including the central budget, local government and community involvement, the private sector, non-governmental organizations and consumers. Recent critiques of public health programmes in Latin America, where per capita social spending is higher than in East Asia but much less effective, have concentrated on the inefficiency and corruption of the public sector. Many countries, however, lack a credible private or NGO infrastructure which could carry the burden of social investment.³³

Among the most important public health reforms is to integrate single-purpose or "vertical" programmes into the structure of primary health care, so that a range of services can be offered under one roof. There has been some success with integrating maternal care, immunization and treatment of childhood diseases, but only mixed results with other programmes, for example STD/HIV prevention and family planning. Matching administrative reform with a shift in medical practice towards more holistic approaches to health care has only just begun, led by NGO initiatives.

Administrative integration gives reproductive health higher priority and visibility. Integrated services provide better opportunities for career advancement which attracts better managers, and they improve links with other services to which clients can be referred if necessary.

Integration should result in a wider range of services in more places at more convenient hours. It offers the opportunity for a full assessment of a patient's situation, including family or personal circumstances which might affect care or treatment.

Integrating Reproductive Health Care

Integration is important for improving the quality of reproductive health care, but providing quality services on such a broad basis will not be easy for developing countries' constrained health budgets and limited staff. It will call for concentration of resources, a redirection of emphasis within the health service towards integrated primary health care, and an emphasis on staff training and career development, as well as the imaginative use of all available means of service delivery to make the most of limited staff and funds. Nevertheless, evidence is growing that many countries are prepared to make this investment in the future.

Higher levels of use of integrated maternal- child health and family planning services have raised use of modern contraception. In Morocco, for instance, the impact of service integration (which is still only partial) on family planning has been relatively small, but the improved service quality could both increase use of services and accelerate improvements in women's and children's health.³⁴

Integrated reproductive health care for women is more than a question of establishing service delivery points. Women often know little about their physiology, causes of ill-health and possible danger signs. They often accept the common view that their health is a low priority; they may simply endure chronic but treatable conditions; or they may not recognize how serious their situation is, as among patients with cervical cancer in Zimbabwe.³⁵ Some sexually transmitted diseases are asymptomatic for long periods: when symptoms appear, they may be connected with stigma and shame and hidden rather than treated. Pregnant women may avoid seeking early prenatal care because they think it impolite or bad luck to admit pregnancy until it is relatively advanced and visible.³⁶ A key objective of integrated reproductive health care is to ensure that women know their options and can exercise them. In that sense it goes beyond the clinic and into the wider society. More-educated women know more about health and are more effective users of such information and services as exist; they are also usually better able to afford care.



Prenatal Care, Attended Births

Maternal and child health services are available more widely than ever before, but the task of making them universally available is bigger than anyone expected. Reducing maternal mortality to reach the goals accepted by the international community (reduce the 1990 level by half by year 2000 and by half again by 2015) calls for broad availability of emergency obstetrical care to handle complications of birth and delivery. It also calls for attended birth to be the norm rather than the exception.

Birth with the help of a trained attendant³⁷ is nearly universal in the industrialized countries but varies widely elsewhere: in countries of Latin America and the Caribbean between 55 and 98 per cent;³⁸ between 2 and 77 per cent in sub-Saharan Africa;³⁹ between 16 and 97 per cent in North Africa and West Asia.⁴⁰ The widest variation is in Asia. In South-central Asia generally few women receive trained birth assistance: Nepal (6 per cent), Bangladesh (10), Pakistan (19), Bhutan (20), India (33); Iran (70) and Sri Lanka (97) are exceptions. Most East Asian countries by contrast show very high levels of trained birth assistance.⁴¹



In many societies, including some industrialized countries, childbirth is seen as an everyday affair rather than as a medical risk, and home birth attendants have no specific training other than experience. Early signs of medical complications may pass unnoticed; more serious conditions calling for emergency care cannot be dealt with and the steps which can be taken to ensure survival until help arrives are unknown. Many attendants do not know how to find emergency help.

Many health services have trained birth attendants to be on the lookout for problems, to refer women with early danger signs to the medical services and to link up with emergency care in case of complications. But that does not solve the problem of providing trained medical staff, emergency blood supplies, medicines and equipment. Some attendants resent interference by the medical services; rural and poor women—who are at the highest risk of death from childbirth—may take their advice rather than seek medical help. Both mothers and attendants, as well as the medical services, need to know each others' strengths and weaknesses, and learn to work together.

Quality of Care

The quality of service has a striking impact on the reproductive health and choices of men and women. The challenge for reproductive health programmes is to provide access to services with the highest feasible levels of quality.⁴²

Because integrated reproductive health is a relatively new concept, systematic information from family planning programmes is not matched by information on other aspects of reproductive health, for example maternal mortality and morbidity or STDs. Many programmes offer the various services at the same primary health centres, however, so deficiencies noted in family planning services—for example lack of water, electricity and equipment—are common to all services. Studies of maternal death also reveal insufficient or under-trained staff, unavailability of blood supplies, shortages of essential drugs including antibiotics, and missing supplies and equipment.⁴³

Facilities

A relatively small number of service delivery points (SDPs) serve a large proportion of clients—as many as 65 per cent of clients go to as few as 25 per cent of the available delivery points. Some of this is the result of concentration of populations and service users: urban areas are both densely populated and inhabited by people who want smaller families. But clients who have alternatives will often choose better service over convenience, leading to heavy use of better SDPs. It is impossible to set an international standard: facilities should be the best achievable given local and national conditions. Important factors are physical infrastructure, equipment and supplies and trained staff.

The physical state of the SDP reflects the relative importance assigned to the service, and influences the confidence of users. Some elements affect more than just appearance: clean water, light and power, sterilizers for reusable equipment, and fresh supplies of disposables are all health issues:

• Studies in Indonesia found that between 37 and 89 per cent of SDPs in nine districts had piped running water.⁴⁴ Adequate water (not necessarily piped) was found in 83.2 per cent of examining rooms in Pakistan, but only 48.4 per cent provided light and cleanliness as well.⁴⁵
  
  
• Studies in sub-Saharan Africa showed that more than a third of SDPs in Tanzania and Zimbabwe lacked sterilizers; between 50 and 70 per cent in Ghana, Nigeria and Burkina Faso lacked them. Blood pressure gauges were lacking in between 20 and 50 per cent of SDPs in six of eight countries studied.⁴⁶

Identifying the reproductive health needs of any individual or couple requires the free and confidential exchange of information between service providers and interested clients, which calls for privacy during both examination and counselling. In Pakistan, privacy was ensured in nearly 80 per cent of examining rooms, but in only 31 per cent of the counselling rooms.⁴⁷ Particularly in overcrowded public clinics, clients spend little counselling time with health practitioners. Discussion is often limited to information needed by the provider; general health concerns, alternate treatments, side-effects or conditions in the patient's life related to the presented problem are rarely discussed. A recent study ⁴⁸ found that family planning clients often received better counselling than clients coming for other maternal and child health services, though only a minority of either kind of client had suitable consultations.

Training, Supervision and Accountability

Maintaining quality of services also requires adequate supervision and monitoring of service deliverers. Available information suggests that in many places supervisory visits are infrequent and rarely involve observation of client-provider interactions. Better monitoring is urgently needed to ensure improvements in quality of service.

Increasing the accountability of services to the clients will also accelerate improvement. Good services ask for and act on client recommendations. Services improve, and clients are more satisfied with their encounters and more likely to continue using the service point.⁴⁹ Without this feedback, dissatisfied clients may go to private services or elsewhere in the public system. People with no alternative to poor-quality public services will simply stop using them altogether.

The gender of health care providers can also affect women's use of health services and the quality of care they receive. In some societies women are reluctant to be examined by male physicians, and a male physician may be unwilling to touch a woman without explicit approval from her husband. In some cases a woman may be reluctant to interact with a man outside her family, even a physician, even in an emergency.⁵⁰ On the other hand, it can be very difficult to find women physicians, especially outside the large towns. That leaves women's diagnosis and treatment in the hands of midwives or nurses, who may not be adequately trained for the purpose.

Response to Reproductive Health Needs

Moving from family planning to reproductive health care cannot be ensured unless interested men and women can discuss their circumstances and needs—their reproductive intentions, their state of health, their cultural understandings, their stage in the life cycle, their capacities for effective use of contraceptive methods and their experience of side-effects.

Contraceptive preferences vary significantly between and within regions. Cultural understandings contribute to some of this variation (for example, the low use of sterilization in Africa and West Asia, and the heavy reliance on condom use in Japan). Programme or provider preferences also make a contribution in some countries.

Service providers must provide information on, for example, side-effects, counter-indications for particular methods (for example, breastfeeding for oral contraceptives, sexually transmitted diseases for IUDs), and be prepared to make disinterested recommendations. This sort of discussion need not take long, though establishing rapport with clients (particularly new clients) requires some time and attention.

Unfortunately, little systematic information is available about the duration of contacts with clients, though first visits generally are longer than visits for resupply.⁵¹ New users are not often asked whether they discuss family planning with their spouses or partners. Their sexual practices and those of their partners are rarely explored because it makes providers uncomfortable, even when they appreciate the value of such discussions in assessing risks and making recommendations.⁵²

Candour about side-effects can allay fears and misunderstandings as well as help new users to find a method with which they can be comfortable, but such frankness is often missing. New users of contraception were informed about side-effects only between 25 and 54 per cent of the time in a variety of settings in sub-Saharan Africa. A wide range of variation in discussion of possible side-effects has also been observed in Indonesia (between 9 and 63 per cent in different districts).⁵³ The same applies to information about how methods work, how effective they are and which to avoid. The presence of reproductive tract infections, for example, indicates that IUDs should not be recommended; yet limited studies in Africa, Asia and Latin America showed that new clients were asked relatively infrequently whether they were experiencing common symptoms of RTIs. Information was occasionally asked about unusual discharges (between 7 and 45 per cent of clients) or pelvic pain (21 and 52 per cent of clients), but not necessarily about both.

Inquiry is not always systematic. In Ghana, nearly 84 per cent of clients were asked about their reproductive goals (spacing or limiting pregnancies) and the discussion was initiated about equally by providers and clients. However, only 44 per cent were asked the number of children they wanted and 46 per cent were asked about their knowledge of family planning. Only 39 per cent were asked about their previous family planning usage. Just under half of clients were asked if they had a method preference; half the clients mentioned a preference before being asked by the provider. Though it is an important consideration in decisions concerning use of the pill, only 36 per cent of clients were asked whether they were breastfeeding.⁵⁴

Poorly trained or biased staff can skew choices by suppressing information or supplying it in an unbalanced way—stressing or omitting information about side-effects for example. Provider beliefs can also affect what they recommend and to whom. Alternative methods and the possibility of switching methods are discussed relatively infrequently with returning clients, often 50 per cent of the time or less. This is of particular concern where programmes do not offer clients choices among a range of safe and effective methods: particularly where potential clients are directed to methods according to age, ethnicity or parity without regard to medical considerations.

Training staff in appropriate counselling techniques and the development of guidelines and protocols for information exchange with clients is sorely needed. In many countries the average provider has not received refresher training for over five years, despite changes in methods available, in counselling techniques and in the orientation of the service towards reproductive health.

Follow-up

Repeat visits by family planning clients tend to be very short and routine, and are usually only to renew supplies. Staff do not often ask whether reproductive intentions have changed, so users are offered little information on alternatives. This can be important for overall reproductive health— for women in mid-life who want no more children and whose health might benefit from a long-term method, for a couple who may be ready to start a family, or for those who need protection against possible STDs, not just pregnancy.

Clinics are also often ill-equipped to follow up with clients who do not return, and thus fail to establish a relationship that would tell health providers more about the reproductive health needs and wishes of their clientele. Without this kind of follow-up, health risks increase—from unintended pregnancy, but also from continuation of an inappropriate method or unprotected sex.

Properly maintained record keeping systems would allow better dialogue and follow-up, but the key lies in the attitudes of staff—if they are concerned only to maintain their records of family planning users, they will be less interested in clients as individuals. With a more inclusive approach (which must come from the policy level, with appropriate training and supervision) family planning takes its place in the range of measures available to protect and promote reproductive health. Clients have more confidence in the service, and service providers in turn can raise reproductive and sexual health issues that may not be revealed by a single visit.

Discussion of and referral for additional health services, including reproductive health concerns beyond family planning, remains the exception rather than the rule in most programmes, although excellent reproductive health programmes have already been instituted in some countries.

Choice of Family Planning Methods

The wider the range of methods available the closer the fit between reproductive desires and realities, and the smaller the number of people who wish to space or limit births and do not do so.⁵⁵

Reproductive health needs change in the course of a lifetime. Individual needs and preferences also vary from client to client. Facilities should be able to respond with, for example, a range of contraceptive options that allows for preferences and personal circumstances and ensures confidence and continuity. Shortages can happen where demand is increasing quicker than supply or delivery systems are weak. In one African study, condoms were unavailable in 10 to 20 per cent of delivery points visited.⁵⁶ Shortages of oral contraceptives were noted in Tanzania and Zaire.⁵⁷ IUDs were more frequently unavailable in a variety of settings.⁵⁸

Periodic surveys in 1982, 1989 and 1994⁵⁹ chart an increase in the availability and accessibility of single contraceptive methods and in the range of contraceptive choice in most countries. The number of countries in which at least 50 per cent of the population has access to temporary methods of contraception has increased steadily over this period. More than half the people in 75 per cent of countries had access to at least one contraceptive method; in Latin America and the Caribbean and in Asia over 80 per cent of countries, in Africa, nearly 60 per cent of countries, and more than half the countries in all regions.



Current contraceptive use is now approaching 60 per cent,⁶⁰ compared with an estimated 57 per cent in 1991. In the less developed regions, prevalence reached 53 per cent in 1991 and 56 per cent in 1995. Globally, 87 per cent of family planning users rely on modern methods. In the less developed regions, 91 per cent of contraceptive users rely on modern methods; in more developed regions 73 per cent do.⁶¹ Regional variation is considerable. Sub-Saharan Africa has the lowest contraceptive prevalence (13 per cent) and the lowest reliance on modern methods (67 per cent) among developing regions. All other developing regions rely on modern methods for more than 80 per cent of usage; Northern Africa and Eastern Asia, for more than 90 per cent.

Sterilization accounts for 40 per cent of global contraceptive use. It is highest in Asia (except Western Asia) and the Americas and uncommon in sub-Saharan Africa, West Asia and Eastern and Southern Europe. Female sterilization is much more common than male (18 and 4 per cent of couples) and is the method with the greatest increase in usage in recent years. IUDs account for about a fifth of world contraceptive use. About two thirds of the world's users live in China (where a survey in 1992 indicated one third of couples were using them).

Unmet Needs for Reproductive Health

The ICPD estimated that 350 million couples worldwide lack access "to the full range of modern family planning methods."⁶² It is estimated that 120-150 million married women worldwide wish either to have no more children or to delay their next birth at least two years but are not using any method of family planning. This "unmet need for family planning"⁶³ does not include important categories of people, such as:

• people in need of STD prevention and treatment, infertility services, safe childbirth, maternal and child care, and sexual health services: The family planning origin of the concept of unmet need is reflected in the lack of information about needs in other areas of reproductive health. Any estimates would need to take into account approximately 175 million pregnancies per year, the 333 million annual new cases of STDs, the 60 million infertile couples and the men and women of all ages lacking reproductive and sexual health.
  
  
• unmarried adolescents and adults: "Unmet need" estimates include only married women of reproductive age, not the millions with sexual partners outside marriage. Available data show that these add at least 10 per cent to new contraceptive users.⁶⁴ A larger proportion probably have an unmet need for family planning. Their broader reproductive health needs are largely unmet because they do not have information or services; because they or the providers are uneasy; or because of procedural barriers, social disapproval or cost.
  
  
• poorly served contraceptive users: Millions of people are using methods which are not appropriate to their age, reproductive intentions or health needs. This may be the result of:
  
  — wrong information on the part of provider or client;
  
  — service system biases favouring particular methods;
  
  — limited choice of methods;
  
  — inadequate attention to the client's sexual experience;
  
  — inadequate discussion.
  
  This group also includes people who are dissatisfied with their current methods because of difficulty of use or side-effects, or because their partners are uneasy.
  
  
• women at extra risk: Millions of women who face additional risks in pregnancy are not using family planning and do not say they want to delay or prevent their next birth. Women at extra risk are under 20 or over 35, have had five or more children, or have had children less than two years apart.⁶⁵ They include women who were ill after their last birth, or who suffer from chronic illness or anaemia. Many of them have no information on the risks they run, and therefore cannot make an informed choice about family planning.

About 200,000 maternal deaths per year can be attributed to the lack or failure of contraceptive services and the consequences which result.⁶⁶ At least 75 million of the 175 million pregnancies each year are unwanted, resulting in 45 million abortions and 30 million live births.



Lifting the Barriers

Some formal barriers to service provision remain in a variety of national programmes; informal barriers are raised by providers' attitudes and organizational procedures.

Fourteen countries require spousal authorization for a woman to receive any contraceptive services.⁶⁷ An additional 60 countries require spousal authorization for permanent methods. This has the effect of denying services to unmarried women, including adolescents and the divorced or widowed, as well as to women who wish to delay or limit births but who cannot negotiate with or persuade their husbands. Spousal authorization restrictions are often applied only to women or differently to men and women.

Women face additional restrictions on sterilization access. Fifty-six countries set a minimum age. Some restrictions may be designed to prevent ill-considered early choices (one country dissuades sterilizations below age 20; six more restrict it below age 24). However, 32 countries restrict it below age 30, 10 below age 35. Fifty countries restrict sterilization in families below a specified size: 17 require four or more children; 16 require two or three children, and one denies sterilization services to those without children. One country uses a formula to determine eligibility: the woman's age times the number of children must exceed 120; the effect is that younger clients may obtain sterilization only if they have had several children. Other countries use sliding scales which allow sterilization of older clients at smaller family sizes. Many of the countries which impose age or parity requirements (and 14 additional countries without either) have procedural restrictions such as requiring medical certification.

In recent decades many contraceptive import restrictions have been repealed or allowed to lapse.

Barriers to information provision include advertising restrictions and limited information programmes in schools. Age-appropriate sex education is now widely used, often designed with the help of parents and community groups, but such information is often restricted to higher levels of primary education, even in countries where the proportions of children (and especially girls) reaching these levels remain low.