INTRODUCTION TO REPRODUCTIVE HEALTH

& SAFE MOTHERHOOD

By:- Wakeshe W (BSc/,MPH/RH, PhD student)

06/22/2024 1
Introduction
Definition
 Reproductive health is defined as
“ a state of complete physical, mental and social
well-being, and not merely the absence of disease
or infirmity, in all matters relating to the
reproductive system and its functions and
processes.”

International Conference on Population and Development,

Programme of Action, 1994.

06/22/2024 2
Sexuality

 “Sexuality is a central aspect of being human

throughout life and encompasses sex, gender
identities and roles, sexual orientation,
eroticism, pleasure, intimacy and
reproduction”
WHO
2002
Sexual Health

“Sexual health is a state of physical, emotional,

mental and social wellbeing in relation to
sexuality; it is not merely the absence of
disease, dysfunction or infirmity”
 5
RH CARE

“The constellation of methods,

techniques and services that
contribute to reproductive
health
and well-being by preventing
and solving reproductive health
problems.”
Reproductive health includes:
•Satisfying, safe sex life
•Ability to reproduce
•Successful maternal and infant survival and
outcomes
•Freedom to control reproduction
•Information about and access to safe, effective,
affordable methods of family planning
•Ability to minimize gynecologic disease throughout
life
 Reproductive health is life-long, beginning even

before women and men attain sexual maturity and

continuing beyond a woman's child-bearing years.
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 The reproductive years are usually thought of as
the years spanning from menarche, with onset
usually between ages 12 to 14, to menopause at
around age 50.
 For demographic purposes, reproductive age is

usually defined as 15 through 49.

06/22/2024 7
 While we often focus our concerns about
reproductive health on this age span in the
population, the use of the phrase “all stages of
life” in the World Health Organization definition
should remind us about reproductive tract-
related morbidity and mortality, often occurring
beyond the reproductive years, such conditions
as cervical, ovarian or uterine cancer or other
conditions affecting these organs.
 Reproductive health should refer to events

experienced by both men and women.

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Historical development of the concept of RH

 It is helpful to understand the concept and to

examine its origins.
 During the 1960s, UNFPA established with a
mandate to raise awareness about population
“problems” and to assist developing countries in
addressing them.

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Historical development…
 At that time, Concern about population growth
(particularly in the developing world and among the
poor) coincided with the rapid increase in
availability of technologies for reducing fertility -
the contraceptive pill became available during the
1960s along with the IUD and long acting
hormonal methods.

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Historical development…
 In 1972, WHO established the Special Program of
Research, Development and Research Training in
Human Reproduction (HRP), whose mandate
was
focused on research into the development of new
and improved methods of fertility regulation and
issues of safety and efficacy of existing methods.
06/22/2024 11
Historical development…
 Modern contraceptive methods were seen as
reliable, independent of people’s ability to practice
restraint, and more effective than withdrawal,
condoms or periodic abstinence.
 Moreover, they held the promise of being able to
prevent recourse to abortion (generally practiced
in dangerous conditions) or infanticide.

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Historical development…
 Population policies became widespread in
developing countries during the 1970s and 1980s
and were supported by UN agencies and a variety
of NGOs.
 The dominant paradigm argued that rapid
population growth would not only hinder
development, but was itself the cause of poverty
and underdevelopment.
06/22/2024 13
Historical development…
 Almost without exception, population policies
focused on the need to hold back population
growth; very little was said about other aspects of
population, such as changes in population
structure or in patterns of migration.
 The 1994 ICPD has been marked as the key
event in the history of reproductive health.

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Development of Reproductive Health

Before 1978 Alma-Ata Conference

 Basic health services in clinics and health centers

 Primary health care declaration 1978

 MCH services started with more emphasis on child

survival
 Family planning was the main focus for mothers

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Development of Reproductive Health …

Safe motherhood initiative in 1987

 Emphasis on maternal health
 Emphasis on reduction of maternal mortality
Reproductive health, ICPD in 1994
 Emphasis on quality of services
 Emphasis on availability and accessibility
 Emphasis on social injustice
 Emphasis on individuals woman's needs and rights

06/22/2024 16
Historical development…

Three rights in particular were identified:

 The right of couples and individuals to decide

freely and responsibly the number and spacing of
children and to have the information and means
to do so;

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 Historical development…
 The right to attain the highest standard of sexual
and reproductive health; and,
 The right to make decisions free of discrimination,
coercion or violence.

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Development of Reproductive Health…

Millennium development goals and reproductive

health in 2000
 MDGs are directly or indirectly related to health
 MDG 4, 5 and 6 are directly related to health,
 while MDG 1,2,3, and 7 are indirectly related to
Health

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Millennium development goals…

 Emphasis on eradicating extreme poverty &

 improving the health & welfare of the world’s
poorest people by 2015.

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THE MISSING GOAL IN MDGS

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 MDGs Relevance to Health Perspective

 Provide a common set of priority for addressing

poverty
 Place health at the heart of the MDGs:
◦ three of the eight are health goals
 Set quantifiable & ambitious targets
 Calls for global partnership for development

06/22/2024 22
 2005 WORLD SUMMIT

 RH was not explicitly prioritized in the MDGs

although many SRH & rights themes appear in
the MDGs
 In 2005 at the World Summit made corrections &
included the recommendation to achieve universal
access to RH by 2015

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Development of Reproductive health
Services in Ethiopia
◦ FGAE was established in 1967 (FP introduced for the fist
time in Ethiopia)
◦ Attempts to integrate family Planning in to MCH program of
the Ministry of Health ( 1979)
◦ Family healthy Department established (1987)
◦ Population Policy developed (1993)

06/22/2024 24
Development…

◦ RH concept introduced in Ethiopia after ICPD

(1994)
◦ National RH needs assessment done (1997)
◦ Ethiopia became the signature of the MDGs
(2000)
◦ National RH strategy developed in 2006
◦ National Adolescent and youth RH strategy
developed in 2007
06/22/2024 25
Rationale: Why RH & Development?
Consequences of unwanted fertility
 RH mortality:
◦ High MMR, PMR
 Sexual morbidity & mortality:
◦ STI/HIV
 Maternal morbidity: Complications of
◦ unwanted pregnancy,
◦ fistula,
◦ maternal depression, cancer 06/22/2024 26
Rationale: Why RH & Development?

 High economic burden to households &

society due to
◦ loss of mothers
 Violence against women
 Gender inequality
 Harmful cultural practices:
◦ Early marriage &
◦ FGM/C

06/22/2024 27
 Objectives of RH care

1. Ensure that comprehensive & factual information & a

full range of RH services, including FP are accessible,
acceptable & convenient for users

2. Enable & support responsible voluntary decisions

about child bearing & methods of FP of their choice,
for regulation of fertility which are not against the law
& to have information, education & means to do so
06/22/2024 28
Objectives of RH ...

3. Meet the changing sexual & RH needs over the

life-cycle & to do so in ways sensitive to the
diversity of circumstances of local communities

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Importance of Reproductive Health

•Reproductive health is a human right stated in

international law.
•Reproductive health plays an important role in
morbidity, mortality and life expectancy.
•Reproductive health problems are the leading
cause of women’s ill health and mortality
worldwide.

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06/22/2024 31
Magnitude of Reproductive Health Problem

 The term “Reproductive Health “is most often equated

with one aspect of women’s lives; motherhood.
 Complications associated with various maternal issues

are indeed major contributors to poor reproductive

health among millions of women worldwide.

 Half of the world’s 2.6 billion women are now 15 – 49

years of age..

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 Magnitude of…
 Without proper health care services, this group is
highly vulnerable to problems related to sexual
intercourse, pregnancy, contraceptive side effects,
etc.
 Death and illnesses from reproductive causes are
the highest among poor women everywhere

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Magnitude of…
 In societies where women are disproportionately
poor, illiterate, and politically powerless, high rates
of reproductive illnesses and deaths are the norm.
 Ethiopia is not an exception in this case.
 Ethiopia has one of the highest maternal mortality
in the world; it is estimated to be between 566 –
1400 deaths per 100,000 live births.

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Magnitude of …
 Ethiopian DHS survey of 2005 indicates that
maternal mortality is 673 per 100,000 live births.(401
in 2017 EDHS.)
 In Ethiopia, contraception use in women is about
27% in 2011 EDHS and 41% in 2019 EDHS of
women want to use contraceptive, but have no
means to do so.

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Magnitude of …

 Women in developing countries and economically

disadvantaged women in the cities of some
industrial nations suffer the highest rates of
complications from pregnancy, sexually transmitted
diseases, and reproductive cancers.

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 Magnitude of…
Lack of access to comprehensive reproductive care
is the main reason that so many women suffer and
die.
 Most illnesses and deaths from reproductive causes
could be prevented or treated.
 Men also suffer from reproductive health problems,
most notably from STIs. But the number and scope
of risks is far greater for women.
06/22/2024 37
 Components of Reproductive Health

1. Quality family planning services

2. Promoting safe motherhood: prenatal, safe
delivery and post natal care, including breast
feeding;
3. Prevention and treatment of infertility
4. Prevention and management of complications of
unsafe abortion;
5. Safe abortion services, where not against the law;
06/22/2024 38
Components…
6. Treatment of reproductive tract infections, including
sexually transmitted infections;

7. Information and counseling on human sexuality,

responsible parenthood, sexual and reproductive
health;

8. Active discouragement of harmful practices, such

as female genital mutilation and violence related to
sexuality and reproduction;
9. Functional and accessible referral 06/22/2024 39
Integrated approaches to reproductive health

Rationale
 To effective link various components of RH.
 To provide complementary RH services either by
the same provider in the same facility or by
different providers in the same area
 To address the need of people and their
concerns

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Advantages of integrated approaches
 It addresses a range of clients RH needs
 It saves time & money for clients as services

are obtained during a single visit

 A single service provider may offer a range of

RH services
 Clients satisfaction & utilization of services

increases

06/22/2024 41
Advantages….

 Clients gain confidence in the service provider

 Coordination & cost effectiveness of services
are improved
 Opportunities to create client awareness of the
availability of other services increase

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Disadvantages

 Health workers require more training and work

loads may be too heavy

 Resource spread more thinly difficult to attribute

expenditures to a specific result

06/22/2024 43
06/22/2024 44
Reproductive health indicators

 Following on a number of international

conferences in the 1990s, in particular the 1994
ICPD, many countries have endorsed a number of
goals and targets in the broad area of reproductive
health.
 Most of these goals and targets have been
formulated with quantifiable and time-bound
objectives. 06/22/2024 45
Evidence for monitoring: Reproductive
health indicators
 A health indicator is usually a numerical measure
which provides information about a complex
situation or event.
 When you want to know about a situation or event
and cannot study each of the many factors that
contribute to it, you use an indicator that best
summarizes the situation.

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Reproductive health indicators …

For example, to understand the general health

status of infants in a country, the key indicators
are infant mortality rates and the proportion of
infants of low birth weight.

06/22/2024 47
RH Indicators…Continued
•RH indicators summarize data that are relevant to
the planning and management of RH programs
•The indicators provide a useful tool to assess
needs, and monitor and evaluate program
implementation and impact
•Indicators are expressed in terms of rates,
proportions, averages, categorical variables or
absolute numbers
Criteria for selecting indicators
Attributes of a good indicator
–Useful: marker of progress towards improved RH
status
–Scientifically robust: valid, sensitive, specific and
reliable
–Representative: adequately encompass all
–Understandable: easy to define and interpret
–Accessible: data available or easy to collect
–Ethical: ethical data collection, processing and
presentation
Conceptual framework
• An important objective of the conceptual
framework is to depict clearly the desired program
and population outcomes targeted by
interventions and the main paths of influence that
connect the pertinent actions
• It helps those involved in program design,
implementation and management to select the
appropriate input, process, output and impact
indicators for M and E
WHO RH Indicators

 Total Fertility Rate Anemia Prevalence

Contraceptive Prevalence Rate Abortion among Obstetric Cases
Maternal Mortality Ratio FGM Prevalence
Infertility Prevalence
Antenatal care coverage Urethritis Prevalence
Skilled birth attendant HIV Prevalence among Pregnant
Availability of Basic Essential Women
Obstetric Care Knowledge of HIV Prevention
Availability of Comprehensive Practices
Essential Obstetric Care Sex Ratio at Birth
Perinatal Mortality Rate
Low Birth Weight Prevalence
Syphilis Prevalence
Inputs Process Outputs Outcomes
Resources Services Results Impacts
Manpower Contacts Knowledge Fertility
Material Visits Acceptance Mortality
Finance Examinations Practice
Morbidity Utilization
Referrals Prevalence

Policies & Products

Procedures Advocacy and IEC
National policies Materials
and legislation Contraceptives
Logistics
 Maternal health care quality, availability and
accessibility can be measured using maternal
Mortality. Indicators are expressed in terms of rates,
proportions, averages, categorical variables or
absolute numbers.
 Reproductive health indicators summarize data
which have been collected to answer questions that
are relevant to the planning and management of RH
programs.
06/22/2024 54
Sources of data for monitoring
Reproductive health
Routine service statistics:

summaries of health service records can give

information and it is very cheap, but may be

incomplete or sometimes may not give enough

information.

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Sources of data….

Population Census:
 The data collected at population censuses such

as population by age and sex, marital status, and

urban and rural residence provide the

denominator for the construction of process,

output and impact indicators.

06/22/2024 56
 Sources of data….
Vital statistics reports: The vital registration
system collects data on births, deaths and
marriages. These data are available by age, sex
and residence. These data provide the numerator
for the construction of process, output and impact
indicators.

06/22/2024 57
Sources of data….

Special studies: collection and summarization

of information for a particular purpose.
Sample surveys : For Example Demographic
and Health survey

06/22/2024 58
Reproductive Health Indicators for Global
Monitoring
There are seventeen reproductive health indicators
developed by the United Nation Population Fund
(UNFPA) which are listed below.
1. Total fertility rate: Total number of children a
woman would have by the end of her reproductive
period, if she experienced the currently prevailing
age-specific fertility rates throughout her
childbearing life. 06/22/2024 59
 TFR is one of the most widely used fertility
measures to assess the impact of family planning
programmes .
2. Contraceptive prevalence (any method):
Percentage of women of reproductive age who are
using (or whose partner is using) a contraceptive
method at a particular point in time.

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3. Maternal mortality ratio: The number of maternal
deaths per 100 000 live births from causes associated
with pregnancy and child birth.
4. Antenatal care coverage: Percentage of women
attended, at least once during pregnancy, by skilled
health personnel for reasons relating to pregnancy.
5. Births attended by skilled health personnel:
 Percentage of births attended by skilled health
personnel. This doesn’t include births attended by
traditional birth attendants. 06/22/2024 61
6. Availability of basic essential obstetric care:
 Number of facilities with functioning basic essential
obstetric care per 500 000 population.
 Essential obstetric care includes, Parenteral
antibiotics, Parenteral oxytocic drugs, Parenteral
sedatives for eclampsia, Manual removal of
placenta, Manual removal of retained products,
Assisted vaginal delivery. These services can be
given at a health center level.
06/22/2024 62
7. Availability of comprehensive essential obstetric
care:

Number of facilities with functioning comprehensive

essential obstetric care per 500 000 population. It
incorporates obstetric surgery, anesthesia and blood
transfusion facilities.

8. Perinatal mortality rate: Number of perinatal deaths

(deaths occurring during late pregnancy, during childbirth
and up to seven completed days of life) per 1000 total
births. 06/22/2024 63
 Total birth means live birth plus IUFD born after
fetus reached stage of viability.
9. Low birth weight prevalence: Percentage of live
births that weigh less than 2500 g.
10. Positive syphilis serology prevalence in
pregnant women: Percentage of pregnant
women (15–24) attending antenatal clinics, whose
blood has been screened for syphilis, with positive
serology for syphilis. 06/22/2024 64
11.Prevalence of anemia in women:

Percentage of women of reproductive age

(15–49) screened for hemoglobin levels with

levels below 110 g/l for pregnant women and

below 120 g/l for non pregnant women.

06/22/2024 65
12.Percentageof obstetric and gynaecological
admissions owing to abortion: Percentage of all
cases admitted to service delivery points providing
in-patient obstetric and gynaecological services,
which are due to abortion (spontaneous and
induced, but excluding planned termination of
pregnancy)
06/22/2024 66
13. Reported prevalence of women with FGM:
 Percentage of women interviewed in a community
survey, reporting to have undergone FGM.
14.Prevalence of infertility in women: Percentage
of women of reproductive age (15–49) at risk of
pregnancy (not pregnant, sexually active,
noncontraception and non-lactating) who report
trying for a pregnancy for two years or more
06/22/2024 67
15. Reported incidence of urethritis in men:
Percentage of men (15–49) interviewed in a
community survey, reporting at least one episode
of urethritis in the last 12 months.

16. HIV prevalence in pregnant women:

 Percentage of pregnant women (15–24) attending
antenatal clinics, whose blood has been screened
for HIV, who are sero-positive for HIV.

06/22/2024 68
17.Knowledge of HIV-related prevention
practices: The percentage of all respondents
who correctly identify all three major ways of
preventing the sexual transmission of HIV and who
reject three major misconceptions about HIV
transmission or prevention.

06/22/2024 69
Reproductive Health rights of adolescents and
women

Background about the Youth

 Young people aged 10-24 constitute 35% of the total population

in Ethiopia

 Young women still suffer high rates of maternal injury and death
due to childbirth without skilled assistance and unsafe abortion.

 Persistent gender inequalities and traditional harmful practices,

including female genital mutilation (FGM) and child marriage,
in addition to limitted access to contraception contribute to these
significant health challenges.

06/22/2024 70
 Background about the Youth…….continued
 Among Ethiopia’s young women ages 20-24, the median age at first
sex is 16.2 years

 Young women and men have very little information and access to
Sexual and Reproductive Health information and services compared
to Adults ( 86% of adult women know about contraceptives
compared to 26 % of young women aged 15-24)

 A national survey taken over the past decade demonstrated that the
unmet need of adolescents is over two times higher than that of the
general population in the country.
International declarations that promote access to
supplies and services

 ICPD at its core promoted healthy, voluntary and safe sexual and
reproductive choices for individuals and couples, including decisions
on family size and timing of marriage.
 ICPD adopted the goal of ensuring universal access to reproductive
health by 2015 as part of its framework for a broad set of development
objectives.
 The Millennium Declaration and Millennium Development Goals set
priorities that are closely related to the ICPD goals
 Leaders ratified the understanding or importance of attaining ICPD
goals to achieve most of MDG goals in the 2005 World Submit.
ICPD & Reproductive Rights
 ICPD Programme of Action articulated and
affirmed idea that reproductive rights
embrace rights established in national laws
and earlier international human rights
documents and other consensus documents
Reproductive Rights
 “Reproductive rights embrace certain human rights that are
already recognized in national laws, international laws and
international human rights documents and other consensus
documents.
 These rights rest on the recognition of the basic rights of all
couples and individuals to decide freely and responsibly the
number, spacing and timing of their children and to have the
information and means to do so, and the right to attain the highest
standard of sexual and reproductive health.
 It also includes the right to make decisions concerning
reproduction free of discrimination, coercion and violence, as
expressed in human rights documents.”
— ICPD Programme of Action, para. 7.3
Examples of UNFPA’s Reproductive
Health Work (1)
 Supporting governments in their implementation of
the ICPD Programme of Action, tracking progress
and monitoring results

 Working with civil society, including faith-based

organizations (FBOs), to advocate for and support
the advancement of ICPD goals
Examples of UNFPA’s Reproductive
Health Work (2)
 Focus on the ‘life-cycle approach’ to sexual
and reproductive health
 Includes helping countries to:

◦ respond to adolescents’ and young people’s SRH

needs
◦ prevent maternal mortality and morbidity
◦ provide women and men (including elderly
women and men) with the sexual and
reproductive health information, goods and
services they require
Examples of UNFPA’s Reproductive
Health Work (3)
 Invests in addressing cross-thematic and intersecting areas
of:
◦ population, poverty and development
◦ reproductive rights, including HIV/AIDS
◦ issues of gender equality and women’s empowerment
within poverty reduction strategies

 UNFPA is designated lead agency for provision of:

◦ HIV prevention-related information and education
◦ condom programming
◦ HIV prevention for young people outside schools
◦ prevention efforts targeting excluded groups, which
includes leading the UN response in the area of sex work
(UNAIDS Division of Labour)
Reproductive Rights: Standards and
Obligations
Reproductive Rights

Progressive Reproductive
Realization rights encompass

Freedoms Entitlements

Vulnerabilities
Reproductive Rights: Standards and
Obligations

Availability
Accessibility
Acceptability 3AQ
Quality

Respect Legal Framework Fulfil

Protect
Concepts and Principles of Rh

Universality

Equality and
Participation Non-discrimination Interdependenc
and e and
Inclusion Indivisibility
Accountability and
Rule of Law
 Reproductive rights Ethiopia signed and committed

Reproductive rights Ethiopia ratified as derived from international

human rights instruments specifically includes the following core
issues:

 Rights to the highest attainable standard of health including a right

to have access to health care as well as access to SRH services and
information

 Right for family planning: to decide on the number and spacing of

their children and to have access to information and services to do
so.
 Reproductive rights Ethiopia …… continued

 Rights to the benefits of scientific progress: everyone

should have access to available technology in reproductive
healthcare, including quality contraceptive options

 Rights of adolescents and unmarried women to receive

SRH information and to freedom of thought : to have
access to family planning information and services

 Rights to non-discrimination on the basis of age: young

people should have the same rights to confidentiality as
adults with regard to their reproductive healthcare.
 Dynamics of Reproductive Health of the Youth

 While the unmet need for contraceptive reduced to 34% for

the general population of Ethiopia, Young people’s unmeet
need remains twice bigger than the general population.

 In a country like Ethiopia where the unmet need is very high

and source of funding for supply of contraceptives is totally
donor –dependent, ensuring contraceptive security
specifically for the most vulnerable groups such as
unmarried youth is very challenging

 Most Young people engage in sex at an early age: One in six

women aged 15-19 years already had their first child and one
fifth of this population is sexually active.
Dynamics of Reproductive Health…. continued

 45 percent of the total births in the country occur among

adolescent girls and young women, which highly expose
them to different reproductive health problems including
fistula

 According to the HIV sentinel surveillance of mothers

seeking antenatal care, HIV/AIDS prevalence is 11 percent
among women age 15-19, and 15 percent among those age
20-24

 Unintended pregnancy and unsafe abortion is also very

high among teenage girls.
Thank you very
much

06/22/2024 85