Women's sexual and reproductive role has largely determined
their social status and economic opportunities. It has shaped their view of themselves and
their sense of personal empowerment, yet they have received little support or care in
fulfilling it. For most women in most societies, the reproductive role has been
simultaneously over-valued and under-supported.
changewhat in effect made it possible to discuss reproductive roles in terms of
rightswas introduced by modern contraception: the possibility of women themselves
controlling the timing and frequency of pregnancy. Contraceptive prevalencethe
proportion of couples using some form of contraceptive methodhas 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 womenas individuals, as family
members and members of a communityare 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
The second section of this chapter discusses sexual and reproductive
health services and related issues.
Poor Women, Poor Health
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.
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
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
Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
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 day7,500 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 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
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
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
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
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.
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
womenwho are at the highest risk of death from childbirthmay 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 servicesfor example lack of water, electricity
and equipmentare 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
A relatively small number of service delivery points (SDPs) serve a
large proportion of clientsas 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
- 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
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
needstheir 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
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 waystressing 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.
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 increasefrom 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 staffif 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
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
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;
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.
Some formal barriers to service provision remain in a variety of
national programmes; informal barriers are raised by providers' attitudes and
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.