C H A P T E R   3
Reproductive Health And Reproductive Rights

Components of Reproductive Health

Key elements of reproductive health include:

• Meeting the need for family planning;
• Ensuring maternal health and reducing infant mortality;
• Preventing and treating STDs, including HIV/AIDS;
• Eliminating traditional practices such as FGM that are harmful to women’s reproductive health and well-being.

Countries are increasingly including other elements such as prevention of cervical and breast cancer and infertility.

Family Planning
Although contraceptive use in developing countries increased by 1.2 percentage points per annum between 1990 and 1995, 5 the needs of about 20-25 per cent of couples are still not being met. The level of unmet need was highest in sub-Saharan Africa (29 per cent) and lowest in Latin America and the Caribbean (18 and 20 per cent). Access to family planning has increased dramatically in some countries, including Nepal and Bhutan. In the Central Asian countries of Kazakhstan, Uzbekistan and Kyrgyzstan, 59 per cent of married couples practise family planning today, compared to less than 20 per cent in 1990.

Many countries have sought to expand the range of contraceptive methods; to improve information and counselling services to enable contraceptive choice with an understanding of the individual’s sexuality, partner and social relations, and gender issues; and to provide more complete and accurate information and counselling on side-effects and their management.

Studies in eight countries found that while women and men are convinced that using family planning and having smaller families provides economic and health benefits, there are many ways programmes can improve.6 The studies found, for example, that side-effects of certain contraceptive methods are more of a problem for women than providers realize.

In all countries, the quality of services can be improved. More specifically, contraceptive counsellors must take into consideration that gender norms may be a barrier for both women and men seeking family planning. Particularly where family planning services are new, where women tend to use contraception clandestinely, and where discontinuation because of side-effects is a problem, networks of established users are needed to help new users. Men and other influential family members should be educated to help them support women’s contraceptive choices.

The diversification of service providers has increased access to family planning services in many parts of the world. For example, over 16 million couples in 55 countries benefited from social marketing in 1997, compared to 14.4 million in 1996, an increase of 13 per cent. Social marketing programmes sold 937 million condoms in 1997, an increase of 20 per cent over sales in 1996. The big increases were the result of the social marketing programmes in India and Indonesia. Increasing sales of condoms also indicate their importance for the prevention of STDs, including HIV/AIDS.

Two new methods of contraception, once-a-month injectables and the female condom, have become available since 1994. Shelf life for the female condom has been extended from three to five years, making it more available to women worldwide. Emergency contraception, a high dose of an oral contraceptive used by women after intercourse to prevent unwanted pregnancy, has also become more accessible since 1994. Methods for male fertility regulation remain severely inadequate, however. More investment is needed in research and development of new methods for men as well as female-controlled barrier methods to prevent both STD transmission and pregnancy. Donor support for contraceptives has increased 15 per cent between 1994 and 1996. 7

Safe Motherhood
The ICPD and other United Nations conferences have stressed that maternal mortality is both a development issue and a human rights issue. The ICPD target is to halve 1990 levels of maternal mortality by the year 2000 — this will not be reached — and reduce them by a further one half by 2015 (specifically, in countries with the highest levels of mortality, to below 60 per 100,000 live births).

In 1997, a meeting organized by the Inter-Agency Group on Safe Motherhood 8 concluded that training traditional birth attendants, providing antenatal screening for high-risk pregnant women, and providing simple birth kits are not enough. Needed are skilled midwives, especially in rural areas, with regulations that permit them to carry out necessary procedures and post-partum care; adequate supplies and equipment backed up by transport in case of emergency; and supportive supervision and monitoring.9

Although progress has been disappointing, some governments have invested in safe motherhood. Tunisia, for example, began its Safe Motherhood Programme in 1990. After the ICPD, the Ministry of Health developed a comprehensive reproductive health strategy including other components such as testing for reproductive cancers, and prevention and management of STDs. In Indonesia, the coverage of antenatal care and supervised delivery significantly improved after the Government developed a programme to train more than 54,000 community midwives.

In Ghana, Uganda, Nigeria and Vietnam midwives have been trained in life-saving skills, using a training package developed by the American College of Nurse-Midwives that includes risk assessment, problem solving and clinical management needed to save the lives of women during obstetric emergencies. Uganda’s Ministry of Health launched a pilot project in one district to establish a sustainable referral system that included strengthening referral facilities, communication and transportation. As a result, obstetric referrals and caesarean sections increased threefold between 1995 and 1996.

Improving maternal health calls for better health facilities, logistic systems and training to ensure appropriate and effective care. Another challenge is to overcome social barriers to access, including improving men’s understanding of their roles and responsibilities in women’s health. This could be critical: a recent survey in Nepal, for example, found that the decision to seek care for pregnant or post-partum women was most often made by husbands, followed by mothers-in-law; the women themselves were seldom involved in the decision.10

Preventing and managing unsafe abortion
Most countries are strengthening efforts to prevent unwanted pregnancies and some are working systematically to reduce the health impact of unsafe abortion, which remains a major public health concern.

Permitting legal access to abortion is a matter for national decision: according to the United Nations Population Division, 189 of the world’s 193 countries allow abortion to save the life of the woman, 120 allow it to preserve the woman’s physical health, 122 to preserve mental health, 83 in cases of rape or incest, 76 in instances of foetal impaiment, 63 for economic or social reasons, and 52 upon request.11 Since 1985, at least 19 countries have enacted new abortion laws or modified existing laws to expand women’s access and choice.12

Studies and programme experience show that the best way to reduce abortion is to prevent unwanted pregnancy by making family planning services more accessible. For example, in the three Central Asian republics of Kazakhstan, Uzbekistan and Kyrgyzstan, better availability of services and information has increased the use of modern contraception by 30-50 per cent since 1990, and abortion rates have declined by as much as half.13

A number of countries (including Kenya, Tanzania, Uganda, Ethiopia, Ghana, Zambia, Nigeria, Malawi, South Africa, Zimbabwe, Mexico, Brazil, Ecuador, Peru, Paraguay, Chile, Nicaragua, Honduras, Guatemala, El Salvador) focus on reducing the health impact of unsafe abortion through post-abortion care. Some countries are training midwives and other providers to offer post-abortion care, including links to family planning services in order to prevent repeat abortions.

In Ghana, a study showed that midwives at primary- and secondary-level health facilities could successfully offer post-abortion care. The study demonstrated improved referral to area hospitals, better community education about unsafe abortion and improved standing of these midwives within their communities.14

HIV/AIDS and Sexually Transmitted Diseases
HIV/AIDS is an even more serious public health problem than ICPD foresaw, particularly in sub-Saharan Africa, with 20.8 mil-lion, or close to 70 per cent of HIV-infected people (see box in Chapter 2 on the demographic impact of HIV/AIDS).

In spite of these figures, several countries still do not recognize HIV as a major threat to public health. In addition, there are approximately 333 million new cases of sexually transmitted diseases each year, but many countries do not have the capacity to diagnose and treat them. Having an untreated sexually transmitted disease can increase the risk of HIV infection tenfold.

In 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) became operational, with a mission to lead, strengthen and support an expanded response to prevent the transmission of HIV, provide care and support, and reduce the vulnerability of individuals and communities to HIV/AIDS. UNAIDS works in full partnership with its 33 United Nations co-sponsors, including UNFPA. Since January 1996, UNAIDS theme groups have been established in most countries to increase the effectiveness of United Nations efforts and to coordinate with national AIDS programmes. NGOs are also members of the theme groups or technical working groups in Brazil, Cambodia, Chile, Democratic Republic of the Congo, Indonesia, Jordan, Rwanda, Swaziland and Viet Nam, among others.

Reproductive health programmes can reduce levels of STDs including HIV/AIDS, by: providing information and counselling in critical issues such as sexuality, gender roles and power imbalances between women and men, and mother-to-child transmission of HIV; distributing female and male condoms; diagnosing and treating STDs; developing strategies for contact tracing; and referring people infected with HIV for further services.

Though health care staff do not generally receive sufficient training and support to provide STD/HIV/AIDS information and services, case studies in four countries in Africa (Burkina Faso, Côte d’Ivoire, Uganda and Zambia) found that providers were willing to discuss sexuality and STDs with clients, and could understand the need to identify individuals at risk of sexually transmitted infections.15

According to a 1997 UNAIDS review of the impact of preventive education on the sexual behaviour of young people, good-quality sex education helps adolescents delay sexual intercourse and increase safe sexual practices.16 Since the ICPD, in 64 countries, support has been provided for the integration of HIV/AIDS prevention modules into in-school and out-of-school education programmes.

In Swaziland, SHAPE (Swaziland Schools HIV/AIDS and Population Education Programme) was launched in 1990 to prevent the spread of HIV/AIDS and to reduce teenage pregnancy in school pupils aged 14 to 19. In 1997, as a result of the ICPD, the programme was also introduced in primary schools. The programme has improved knowledge and attitudes more than behaviour.17

Currently, an estimated 27 million people do not know they are HIV positive, underlining the need for simple methods to diagnose HIV. Countries have already introduced the female condom, the only female-controlled barrier method that can protect against HIV transmission, as a result of the organized demand of women’s groups and in recognition of the importance of supporting women’s control in this area.

A study in Thailand found that a one-month course of an antiretroviral drug effectively halved the risk of HIV infection in non-breast-fed infants born to HIV-positive women. UNAIDS, UNFPA, UNICEF and WHO in 1998 began offering voluntary and confidential HIV counselling and testing to pregnant women in 11 pilot countries. Those who learn they are infected are provided with antiretroviral drugs, better birth care, safe infant feeding methods and post-natal counselling, and family planning.18

Female Genital Mutilation
The ICPD called for an end to female genital mutilation, the partial or total removal of external female genitalia, a practice that has severe health and psychological consequences. Worldwide, an estimated 130 million girls and women have undergone some form of FGM, and each year 2 million are believed to be at risk. Most are in 28 countries in Africa and the Arabian Peninsula. Thousands die each year as a result of FGM, from infections and haemorrhaging or in childbirth.

The Programme of Action called on governments "to prohibit female genital mutilation wherever it exists and to give vigorous support to efforts among non-governmental and community organizations and religious institutions to eliminate such practices".19

In the past several years, efforts to combat FGM have gained strength, largely as the result of advocacy efforts by NGOs such as the national chapters of the Inter-African Committee on Traditional Practices. In early 1999, Senegal joined Burkina Faso, Central African Republic, Côte d’Ivoire, Djibouti, Ghana, Guinea, Tanzania and Togo in out-lawing the practice. Similar laws have been proposed in Benin, Nigeria and Uganda.20 In Egypt, the Supreme Court in 1997 upheld a ministerial decree prohibiting physician-assisted FGM as well as a 1959 law criminalizing all FGM in the country.

The practice of FGM is deeply rooted within cultural traditions and eliminating it will require persistent efforts. Some older women insist on having their daughters or granddaughters mutilated to maintain their eligibility for marriage. That is a perception they share with some younger women who fear social rejection if they do not undergo the procedure.

Various culturally sensitive initiatives have been undertaken to show that harmful traditional practices can change without compromising values. In Uganda, the Reproductive, Educative and Community Health gift-giving and public celebration of womanhood for FGM rituals. The campaign, begun in 1995, reduced FGM in the country’s Kapchorwa district by 36 per cent in 1996. The UNFPA-supported programme involves the community at all levels, especially the local elders. Those who practise FGM are given training as traditional birth attendants.

Similarly, the Kenyan women’s organization Maendeleo ya Wanawake encourages alternatives to the coming-of-age rituals surrounding FGM, emphasizing positive cultural traditions of the community. Those who perform FGM are helped to find alter nate means of support.

In Senegal and Egypt, campaigns of women’s rights activists have successfully advocated changing laws and practices regarding FGM. Egypt’s FGM Task Force, composed of activists, researchers, doctors and feminists, played a pivotal role in broadening debate on the sensitive and charged issue of FGM and creating a climate for a political ban on the practice. Government-NGO coalitions are emerging in Mali and Nigeria to fight FGM and violence against women.21

| MAIN MENU | CONTENTS | NEXT |

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