C H A P T E R   1
Overview and Introduction

The five-year review of ICPD recognized the importance of the right to health, including reproductive health, in health-sector reform and made recommendations on programme priorities in family planning, maternal health, prevention of sexually transmitted diseases

(STDs) including HIV/AIDS, and adolescent reproductive health. It urged governments to, among other things:

• Increase skilled attendance in childbirth;

• Review laws affecting reproductive health;

• Increase investments to improve the quality and availability of sexual and reproductive health services, including voluntary, quality family planning;

• Involve communities, non-governmental organizations and the private sector in designing, implementing, monitoring and evaluating programmes;

Providing better information and counselling, and involving communities, leads to greater client satisfaction and increased demand for services.

• Promote male responsibility for protecting their own and their partners’ sexual and reproductive health, preventing unwanted pregnancy and the spread of sexually transmitted diseases, sharing household and child-rearing responsibilities, and helping eliminate harmful practices, coercion and sexual violence;

• Ensure availability of reproductive health information, services and products, including contraceptives, to allow all couples and individuals to exercise their right to decide the number, spacing and timing of their children and to have the information and means to do so;

• Recognize the connection between maternal mortality and poverty, and work to reduce maternal mortality and morbidity as a public health priority;

• Ensure that women have ready access to essential obstetric care, adequate maternal health-care services, skilled attendance at delivery, emergency obstetric care, referral and transport to higher levels of care when necessary, post-partum care and family planning;

• Provide education and services — including voluntary HIV testing and counselling, and access to female and male condoms — to prevent the transmission of sexually transmitted diseases and HIV, as an integral part of primary health care;

• Mobilize society to address the social and economic factors contributing to HIV risk and vulnerability, and promote responsible sexual behaviour based on mutual respect and gender equity in sexual relationships;

• Prevent sexual exploitation of young women and children;

• Ensure that refugees and people in emergency situations receive sexual and reproductive health care and information, and greater protection from sexual and gender-based violence;

• Eliminate harmful traditional practices, such as female genital mutilation;

• Work with parents, communities, schools and youth to ensure that adolescents have appropriate information, assistance and services for responsible and healthy sexual and reproductive behaviour.

Broader choice, better quality
In keeping with the needs-based approach to reproductive health agreed to at the ICPD, the focus of programmes and policies is shifting from service providers to their clients, though not at the same speed in all countries. In successful programmes, results are increasingly being measured by the quality of service and the responsiveness and expertise of service providers.

But it is harder to measure quality than count heads, so a lot of work since the ICPD has gone into finding reliable ways to assess programme performance based on the new criteria, for example by establishing participatory planning, monitoring and evaluation. Lessons learned are starting to be translated into regular cycles of planning, action and review, resulting in continuous improvement. This process is reinforced by training and retraining service providers and securing their commitment to quality service delivery.

Experience in Nepal, the Philippines, Ghana, Kenya and other countries shows that with proper staff training the proportion of clients receiving higher-quality information and counselling can be dramatically increased within a short time, and that community participation amplifies the benefits. Responsive and client-centred programmes, backed by sufficient funding and managerial support, and including attention to multiple health concerns, increase clients’ satisfaction and raise their expectations. This draws more clients into the system, further increasing demand for integrated services. Quality of service affects clients’ choices and encourages health-promoting behaviours.8

These efforts accelerate national programmes’ ability to adjust and adapt to changing circumstances and improve their responsiveness and accountability to the people they serve. They bring out the best efforts of governments, the private sector, and social, voluntary and community-based organizations.

Obstacles
Not all of the reproductive health concerns set out in the Programme of Action however, have called forth the required response:

• It has been hard to secure the necessary resources or policy priority to reduce maternal mortality, despite well-known and widely available techniques, and despite universal agreement that it should be a programme priority. One study found that where maternal mortality is very high — more than one death in every 100 pregnant women — the risk could be reduced by as much as 80 per cent by providing antenatal care, information about warning signs and services to provide emergency care.9

• Providing appropriate information and services for unmarried adolescents and young adults has been difficult in many countries.

• The HIV/AIDS pandemic has advanced faster than projected in 1994 at the time of the ICPD.

Maternal mortality
Reducing maternal mortality and morbidity has been a goal of government policies and programmes since the Safe Motherhood Initiative was launched in 1987, but there has been little or no progress. A systematic effort to reduce the overall risk of maternity calls for a range of interventions, including: skilled help during and after delivery; emergency referral and obstetric care, expanded information and education about health, pregnancy and childbirth, pre- and post-natal care; improved nutrition; and greater access by women to resources, information and the power to make their own decisions. The ICPD review agreed on new bench-marks for reducing maternal mortality.

There has been little progress in reducing the risk of childbirth. Left, nurse in Sierra Leone maternity ward examines patient who had no prenatal care and whose child was stillborn. Sierra Leone has one of the world’s highest maternal mortality rates, 1,800 deaths per 100,000 births.

The youth debate
There are currently over 1 billion young people between the ages of 15 and 24, the largest number ever. Many are married, though fewer proportionately than a generation ago; more are sexually active. Today’s young people are frequently at risk — of unwanted pregnancy, HIV/AIDS and other sexually transmitted diseases, sexual exploitation, and alienation from parents and communities. A key concern is the growing number of young people living outside families or in disrupted family situations.

How best to meet young people’s reproductive health needs is a matter for discussion and national decision. It has often proved difficult to reconcile the important role of parents with the capacity of young people to make their own decisions as they grow towards adulthood, or to define the role of society in mediating what is primarily a family matter.

Ignoring the issue, however, incurs a high cost in ill health, wasted life opportunities and social disruption. There is strong evidence that offering informed choices to the young reinforces responsibility and encourages responsible adulthood and parenthood. On this basis, many countries are designing policies and programmes for youth, including reproductive health; and recognition is growing that the involvement of young people themselves in preparing and putting these programmes into action is essential to their success.10 Some programmes successfully involve older family members and the community in advising and informing young people.

The ICPD agreed that young people have the same right to reproductive health as their elders, though it is acknowledged that the right to reproductive health is a sensitive issue as it regards youth; societies will have different approaches and will come to different conclusions about how to achieve the goal of adolescent reproductive health.

HIV/AIDS
New infections now number 11 a minute, and over half of those infected are young people below the age of 24. Other sexually transmitted diseases are also disproportionately found in younger men and women; an untreated sexually transmitted disease increases the risk of HIV infection tenfold.

Young women are particularly at risk because of biological susceptibility, their vulnerability to unwanted and coerced sex and their inability to negotiate safe sex.

Within groups engaging in high-risk behaviours, HIV prevalence can increase from under 5 per cent to over 50 per cent within one or two years.11 From these groups (for example prostitutes and their clients, others with multiple unprotected sex partners, and needle-sharing drug users) the virus passes readily through social networks and contaminated blood supplies to the general population.

Strong prevention programmes can avert an even more devastating catastrophe. Some affected countries have been very successful in reducing the incidence of new HIV/AIDS infections in young populations. In Uganda and Thailand the incidence of new infections, particularly in young populations, has declined by about one third in response to intensive information and protection campaigns. Among adolescents, in particular, prevalence levels have reversed among young women appearing for prenatal care.

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For more information:
United Nations Population Fund
Information and External Relations Division
220 E. 42nd Street, New York, NY 10017, U.S.A.
Tel. 212-297-5020; fax: 212-557-6416
E-mail: ryanw@unfpa.org. Web site: www.unfpa.org