ADIGRAT UNIVERSITY

COLLAGE OF MEDICINE AND HEALTH

SCIENCE
DEPARTMENT OF PUBLIC HEALTH
Reproductive health course for
Public health officers
2024
by G/hiwot G/mariam( Assistant Prof )

May 26, 2025 1

 Course objectives
• Recognize the new concepts of Reproductive
health
• Determine the international and national
magnitude of maternal morbidity and mortality
• Describe reproductive rights
• Identify and explain the components of
Reproductive Health
• Explain the advantages of an integrated approach
of Reproductive health
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 2
• Course module:PubH2063
• Course code : PubH2062
• Credit hour : 2
• Module category : core

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 3

 Method of Course delivery
• Interactive lecture
• Role play
• Group discussion
• Individual and group assignments
• seminars

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 4

 Evaluation methods
• Group/individual assignments
• Short Tests/quiz
• Final exam

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 5

 References
• Safe motherhood initiatives and mothers Baby
package guideline
• Reproductive health; a family health planning
manuals, guidelines
• National guide line for HIV/AIDS/PMTCT
• Reproductive health lecture note for health
science students 2008.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 6

 Course contents
1. Introduction to RH
2. RH components
3. Harmfull traditional practices
4. Service delivery of reproductive health and
HIV /Aids
5. Monitoring and evaluation of RH
6. Youth reproductive health

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 7

 Brain storming
• Your pre-existing knowledge and experiences
about Rh
• your expectations

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 8

 CHAPTER ONE
INTRODUCTION TO REPRODUCTIVE HEALTH

Definition of Reproductive Health

 Reproductive health is a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity,
in all matters related to the reproductive system and to its functions
and process.

 Reproductive health therefore implies that people are able to have a

satisfying and safe sexual life and that they have the capability to
reproduce and the freedom to decide if, when and how often to do
so.

 Men and women have the right to be informed and have access to
safe, effective system, affordable and acceptable methods of their
choice for the regulation of fertility which are not against the law, and
the right of access to appropriate health care services for safe
pregnancy and child birth.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 9
 Cont… def/n
• Reproductive health care: is defined as the
constellation of methods, techniques and
services that contribute to reproductive health
and wellbeing by preventing and solving
reproductive health problems.

• Sexual Health: is the enhancement of life and

personal relations, and not merely counselling
and care related to reproduction and STDs.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 10

 Rationale for referring the target
population for RH
• To set priority and deliver appropriate services to
high risk groups
• To utilize resources effectively
• To determine the number of eligible for the
services.
• To plan the type of services to be provided
• To focus the efforts towards the target group
• To measure Evaluate changes
• To address equity in delivery of the health services

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 11

The target groups for Reproductive Health services

• Women of childbearing age (15-49years old)

• Adolescents (both male & female)
• Under five years of old children

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 12

Women of child bearing age (15-49 Years old)

 Women alone are at risk of complication from

pregnancy and childbirth.
 Women face high risks in preventing
unwanted pregnancy, they bear the burden
of using and suffering potential side effects
from most contraceptive methods, and they
suffer the consequences of unsafe abortion
 Women are more vulnerable to contracting
and suffering complications of many sexually
transmitted infections including HIV/AIDS.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 13
 Adolescents (Both sexes)

• Adolescents lack reliable reproductive health in

formation.
• leaders, community members, and parent's are
reluctant to provided education on sexuality to young
men and women for fear to promiscuity.
• Many adolescents are already sexually active, often
at very young age.
• The reproductive health status of young people, in
terms of sexual activity, contraceptive, childbearing,
and STIs lays the foundation for the country's
demographic feature.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 14
 Cont… adolescent
• During adolescence, normal physical development may be
adversely affected by inadequate diet, excessive physical
stress, or pregnancy before physiological maturity is
attained.
• Adolescents are at high risk to acquire infertility associated
with STIs and unsafe abortion.
• Conditions of work are designed for adults rather than
adolescents and put them at greater risk of accidental
injury and death.
• Current health services are generally not organized to fulfill
the need and demands of adolescents.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 15
 Under five children
• Children's health is a base for healthy adolescence and
childbearing ages.
• Proper health service for children serves to increase the
opportunities of women to have contact with the health
institution.
• The health of children and women is inseparable.
• The morbidity and mortality of children in Ethiopia is one
of the highest in the world.
• Bearing high member of children has adverse
consequences on health of the mother, the general
income distribution and health status of the family.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 16
 History of RH
Reproductive health in the old paradigm
MCH/FP
• Maternity Care
• Child Health Care
• Family Planning
WHO’s four priorities (1948)
• Tuberculosis
• Malaria
• MCH
• Venereal Diseases
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 17
 MCH emphasis continued
• MCH -Essential component of PHC( Almata,
1978)
• Where is the “M” in MCH? Lancet, 1985
• Safe Motherhood Conference, 1987, Nairobi
Recently
• MNCH continuum of care
• MDGs/ nowadays the SDG

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 18

 WHY SPECIAL CARE FOR MOTHERS AND
CHILDREN
• Majority population ( women are about 23% of the total population
and children under 15 years constitute about 47% in developing
countries)
• Vulnerable group of population

• Problems of mothers and children are intertwined

• Health problems are avoidable

• Voiceless”

• Investment in to the future

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 19
The UN International Conference on Population and Development (ICPD), Cairo 1994

• The 1994 ICPD has been marked as the key event in the history
of reproductive health.

• Focuses on meeting the needs of individual women and men

rather than on achieving demographic targets.

• Recognition of the need to empower women.

• Criticism of the over-emphasis on the control of female fertility

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 20
 ICPD -1994
Reproductive Health
• Paradigm shift: Family planning to Reproductive Health,

• Focuses on meeting individual needs women, men and

young people

• Addresses needs throughout the life cycle (Pre-birth,

infancy, childhood, adolescence, reproductive age and
elderly)

• Represented a major step forward in current thinking about

human sexuality and reproduction
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 21
 Three rights were identified on ICPD
• 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;
• The right to attain the highest standard of
sexual and reproductive health; and,
• The right to make decisions free of
discrimination, coercion or violence

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 22

 Reproductive health rights
• It implies that people have a satisfying and safe sex
and that they have the capacity to reproduce and
the freedom to decide when and how often to do so.
• The rights of couples and individuals to decide freely
and responsibly the number and spacing of their
children, and to have the information and the means
to do so;
• The right of access to appropriate health care
services that will enable women to go safely through
pregnancy and child birth.
• The right to freedom from HTPs.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 23
 Cont… Rights
• The right to information and education on sexual and
reproductive health issues
• The right to choose whether or not to marry and form a
family;
• The right to decide whether or not to have children;
• The right to health care and health protection.
• The right to influence communities and governments to
prioritize sexual and reproductive health rights.
• The right to be free from torture and ill treatment including
the right of all women, men and young people to protection
from violence, sexualby G/hiwot
May 26, 2025
exploitation and abuse.
G/mariam( Assistant Prof 24
 Group discussion
• What are the enabling factors of Rh ?

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 25

 Enabling conditions for RH
• Empowering women and promoting gender
equality and equity
• Eliminating discrimination against the girl child
• Ensuring male responsibility and participation:
• Achieving universal educations

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 26

 Maternal morbidity:
• Any deviation, subjective or objective, from a
state of physiological or psychological well
being of women
Women’s lifetime risk of Death
• Is the risk of an individual woman dying from
pregnancy or childbirth during her lifetime.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 27

 Maternal morbidity and mortality:
A Global and National Perspective
Definition of maternal death
The death of a woman while pregnant or within
42 days of termination of pregnancy,
irrespective of the duration and site of the
pregnancy,
from any cause related to or aggravated by
the pregnancy or its management but not
from accidental or incidental causes.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 28

 Cont…maternal

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 29

 Maternal mortality ratio (MMR)
• The MMR is the…
Number of maternal deaths per 100,000 live
births.
• EDHS 2015 estimated that 420 MMR/100,000
live births in Ethiopia.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 30

CONT…
 Brain storming
• What are possible causes maternal death ?

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 32

 Causes of Maternal Death
Direct Causes
• Obstetrical complications of pregnancy, labor
or the postpartum period
• Includes interventions, omissions, incorrect
treatment, etc.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 33

 Cont… direct cause
• Hemorrhage
• Hypertensive disease (including preeclampsia
and eclampsia)
• Infection and sepsis
• Obstructed labor
• Abortion
• Others (embolism, anesthesia)

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 34

 Indirect Causes
Previously existing diseases, or diseases arising
during the pregnancy which are aggravated by
the physiologic effects of Pregnancy
• HIV
• Malaria
• Anemia
• Cardiovascular disease
• Others
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 35
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 36
 Maternal mortality in Ethiopia
• Abortion(32%)
• Obstructed labor(22%)
• Sepsis(12%)
• Hemorrhage(10%)
• Hypertension(9%)
• Indirect causes(15%)

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 37

 Cause of maternal morbidity by world region

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 38

Estimated average interval from onset of complication to death
for major obstetric complications

• Anti partum hemorrhage 12 hours

• Post partum hemorrhage 2 hour
• Rapture uterus 1 day
• eclampsia 2 days
• Obstetric labor 3 days
• Puerperal sepsis 6 days

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 39

 Cont… maternal

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 40

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 41
 Obstetric Care -Categories
Provision by numerous providers
Unskilled”
• Mother, family
• TBA
• Trained birth attendant
“Skilled”
•Trained midwife, nurse-midwife
•Trained physician
•Obstetrician/gynecologist
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 42
classifications of OBSTETRIC intervention.
• Essential and recommended in all
circumstances for increasing maternal
survival.
• May be appropriate for good preventive
health care but not significantly associated
with increase maternal survival.
• Unnecessary and may be divert efforts and
resources or create barriers to access.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 43

 Essential and recommended…
• Family planning
• Birth preparedness and complication
readiness.
• Identifications and treatment of illnesses(pre
eclampsia, previous cesarean section)
• Immunization and prophylaxis
• Routing practices (clean delivery, active mgt of
third stage of labour).
• Emergency obstetric care.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 44
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 45
 Maternal Mortality in context of three
delays
1. Delay in deciding to seek care
• Failure to recognize signs of complications
• Failure to perceive severity of illness
• Cost consideration
• Previous negative experience with the health
System
• Transportation

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 46

2. Delay in reaching care
• Lengthy distance to a facility
• Conditions of roads
• Lack of available transportation
3. Delay in receiving appropriate care
• Uncaring attitudes of providers
• Shortages of supplies and basic equipment
• Non-availability of health personnel
• Poor skills of health providers

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 47

 SAFE MOTHER HOOD INITIATIVES

• In 1987 the World Bank, in collaboration with WHO and

UNFPA, sponsored a conference on safe motherhood in
Nairobi, to help raise global awareness about the impact of
maternal mortality and morbidity

• The conference launched the Safe Motherhood Initiative

(SMI), which issued an international call to action to reduce
maternal mortality and morbidity by one half by the year
2000.

• It also led to the formation of an Inter-Agency Group (IAG)

for Safe Motherhood, which has since been joined by
UNICEF, UNDP, IPPF, and the Population Council.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 48
 Con’t…..SMI
• Safe motherhood is a woman’s ability to
have a safe and healthy pregnancy and
delivery.
• Nearly every minute, one woman dies from
the complications of pregnancy and
childbirth.
• That is more than 500,000 women dying
each year; 99% of these deaths occur in
the developing world

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 49

 Cont…smi
• The SMI's target has subsequently been
adopted by most developing countries.
• Under the Safe Motherhood Initiative,
countries have developed programs to reduce
maternal mortality and morbidity

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 50

The strategies adopted to make
motherhood safe
• Providing family planning services.
• Providing post abortion care.
• Promoting antenatal care.
• Ensuring skilled assistance during childbirth
• Improving essential obstetric care.
• Addressing the reproductive health needs of
adolescents

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 51

 Essential Services for Safe
Motherhood
• Safe motherhood can be achieved by
providing high quality maternal health
services to all women through linked with
community health care providers, clinics and
hospitals.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 52

 Cont… safe mother hood components
• Community education on safe motherhood
• Prenatal care and counseling, including the promotion of
maternal nutrition
• Skilled assistance during childbirth
• Care for obstetric complications, including emergencies
• Postpartum care
• Post-abortion care and, where abortion is not against the
law, safe services for the termination of pregnancy
• Family planning counseling, information and services
• Reproductive health education and services for
adolescents
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 53
 CHAPTER TWO

COMPENENTS OF REPRODUCTIVE
HEALTH

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 54

 2.1. Gender based violence

What is violence ?
What is sexual violence ?

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 55

 Gender-based violence

• Gender-based violence is an umbrella term for any harmful act that

results in, or is likely to result in, physical, sexual or psychological
harm or suffering to a woman, man, girl or boy on the basis of their
gender.
• GBV is a result of gender inequality and abuse of power. GBV
includes but is not limited to sexual violence, domestic violence,
trafficking, forced or early marriage, forced prostitution, sexual
exploitation and abuse and denial of resources, opportunities and
services

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 56

 Sexual Violence
Violence
• Violence the exercise or threat of physical force or coercion
(the exertion of force so as to injure or abuse).
Can be physical or sexual
• Sexual abuse - sexual coercion and sexual violence is
increasingly being acknowledged as a global problem
involving as many as one in four young women
• Many young boys experience sexual violence;
• Sexual abuse contributes to adolescent pregnancy, HIV and
STIs.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 57

 Definition con’t…
These acts include:
• Sexual abuse, including of female children;
• Dowry-related violence;
• Rape, including marital rape;
• Female genital mutilation/cutting and other
traditional practices harmful to women;
• Non-spousal violence;
• Sexual violence related to exploitation;
• Sexual harassment and intimidation at work, in
school and elsewhere;
• Trafficking in women

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 58

Women may face different forms of violence at different
stages of their lives.
Phase Type of Violence
Prenatal sex selection, battering during pregnancy, coerced
Prenatal pregnancy (rape during war)

Infancy Female infanticide, emotional and physical abuse, differential

access to food and medical care

Childhood Genital cutting; incest and sexual abuse; differential access

to food, medical care, and education; child prostitution

Adolescenc Dating and courtship violence, economically coerced sex,

sexual abuse in the workplace, rape, sexual harassment,
e forced prostitution

Reproducti Abuse of women by intimate partners, marital rape, dowry

abuse and murders, partner homicide, psychological abuse,
ve sexual abuse in the workplace, sexual harassment, rape,
abuse of women with disabilities

Old Age Abuse of widows, elder abuse (which affects mostly women)
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 59
 Group assignment
Discuses the physical, mental, social and
psychological impacts of violence

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 60

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 61
 Individual Level Interventions
• Psychotherapy
• Behavior Modifications
• Cognitive-Behavioral
• Self-esteem Building
• Anger Management
• Drug Treatment

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 62

Parent Level Interventions
• Positive Parenting
• Home visitation programs
• Multi-systemic Therapy (MST)
School Level Interventions
• Bullying prevention
• Classroom Management

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 63

Community Level Interventions
• Community Rebuilding
• Community Policing
• Gang Reduction
• Mentoring
• School/Community/Parent Interventions

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 64

What Can Be Done Against Gender Based
Violence (GBV)?
• The most effective approach is integrated and
multi-level
• police and judicial reforms, legislative initiatives,
• community mobilization to encourage behavior
change, and the reorientation of health services.
• provides services for victims and punishes
perpetrators, while in the long term it addresses
the social and economic determinants of
violence.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 65
 Cont…
• Prevention strategies also need to focus on:
Empowering women and raising their status
Combating norms of violence, and
Reducing poverty and alcohol consumption

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 66

 2.2. Maternal health

2.2.1. Anti natal care

• Antenatal care refers to care given to pregnant
women so that they have safe pregnancy and
healthy baby.
• Pregnancy is a normal physiological process
associated with certain risks to health of the
woman and the infant she bears.
• Antenatal care (ANC) strategies target pregnant
women to reducing maternal and prenatal
mortality and morbidity
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 67
 Benefits of anti natal care
• screen and detect early signs of or risk factors for
disease.
• Timely intervention of care during pregnancy.
• benefits to the baby in terms of growth, risk of infection,
and survival,
• To emphasize the promotion of health and health-
seeking behavior of the mother.
• To develop birth preparedness and complication
readiness.
• To provide anti malarial drugs/prophylaxis or of
antiretroviral therapy for maternal HIV/AIDS.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 68
 Component of ANC
• Health promotion and education
• Assessment, management and/or referral through
history-taking, physical examination, and laboratory
• tests, where necessary;
• Tetanus toxoid immunization;
• Iron and folate supplementation;
• Malaria prophylaxis;
• Hookworm treatment/prophylasis and
• STD management.
• Development of birth preparedness and complication
readiness.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 69
 TRADITIONAL ANC
• Ritualistic rather than rational
• Emphasis of visits is on frequency and
numbers of visits, rather than on essential
goal-directed elements of each visit.
• Communication is minimal, and focused on
findings
• Preparation/planning is not stressed

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 70

 Cont… traditional
• Emphasis on risk screening(identifying women who
would face problems)
• Through history taking, physical and laboratory
examination
• Providing(Td immunization, iron/folate
supplementation..)and treatment as appropriate
• Education on maternal health and nutrition
• Assigning number and timing of ANC visits
–Every month-Up to 28 weeks of gestation
–Every 2weeks-29to36weeks
–Every week 37weeks
May 26, 2025 and
by G/hiwot G/mariam( above
Assistant Prof 71
 When is risk screening effective?
• The whole population (pregnant) is included
• Conditions screened should include major causes of
morbidity and mortality
• When increased risk is detected, appropriate actions
should be taken
• Adequate services should be available at the referral level.
• Women at risk should be able to reach the referral
services
• Care providers must be motivated to implement the
system
• The strategy must show reduction in maternal morbidity
and mortality
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 72
 CRITICISM AGAINST TRADITIONAL ANC

• Risk factors are not usually the direct cause of complication

• Risk approach does not distinguish those who would
develop complications from those who would not.
• Only 10-30% of high risk women experience adverse
outcomes.
• Many women categorized as low risk develop complications
but are never told how to recognize or respond to them
• Consumes scarce resources.
• Currently it is recommended to conduct goal oriented
interventions that have evidence of being effective.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 73
 Focused anti natal care
• 4-5 ANC visits effective interventions (i.e, goal
oriented visits).
• Similar maternal results as for higher numbers of
ANC visits
• Prevention, detection, investigation of anemia and
treatment of iron deficiency anemia reduces
maternal anemia.
• All pregnant women should have a minimum of
four antenatal visits (at least 20 minutes duration each)

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 74

 Recommended elements of FANC
• Birth preparedness:
–planning for a skilled attendant,
–counseling danger signs of pregnancy
•Complication readiness:
-planning for emergency funds, transport, blood
donor, designated decision-maker
• Counseling/service provision
–family planning, nutrition, mother-to child
transmission of HIV
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 75
 The New ANC eight contact Model

• Based on the WHO 2016 Recommendation

• Health pregnant mother should have eight
contacts during her pregnancy life time

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 76

2016 WHO ANC model
 ANC history and physical examination
during first contact
• Identification: Name, address,
• Menstrual history: date of first LMP and
regularity of the menses; current or previous
breastfeeding, use of contraception; determining
the gestational age and EDD
• History of present pregnancy:
• Intention of the present pregnancy:
• Past obstetric history:
• Medical history:
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 78
 Con’t…
• Current medication: including therapeutic medicines, illicit
drugs, herbal/traditional remedies, drug allergy
• Gynecologic history: including screening for cervical cancer,
gynecologic surgery, STI
• Nutritional history:
• Social and personal history: including use of alcohol,
tobacco, exposure to second-hand smoke, khat, caffeine in
large quantity (>300 mg/day or >3 small cups of Ethiopian
coffee), or other harmful substances, assessing for intimate
partner violence, female genital mutilation (FGM)
• Mental health:
• Intimate partner violence:
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 79
 Physical examination
• General appearance for pallor, respiratory distress
• Vital signs: blood pressure, pulse rate, respiratory
rate, temperature
• Weight and height:
• Acute malnutrition screening: using MUAC
• Examining the conjunctiva, oral mucosa, and nail
beds for pallor
• Auscultating the chest for breathing sounds and
heart sounds, any additional sounds
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 80
 Con’t..
• Obstetric examination: Measuring the symphysis
fundal height and doing the Leopold maneuvers
• Auscultating the fetal heartbeat
• Examining the musculoskeletal system for any gross
deformity/swelling, varicose veins in the lower limb
• Examine for any sign of trauma like bruises that would
indicate intimate partner violence
• Examining the FGM scar after consultation and
deciding on the need of deinfibulation (in high
prevalence areas)
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 81
 Basic and case-specific ANC screening
The following tests should be done for all pregnant women.

• Hemoglobin (Hb) or hematocrit (Hct), blood group, and Rh

• Urine analysis: dipstick, microscopy and gram stain Tests for
HIV, HBV, syphilis

• Ultrasound before 24 weeks: One ultrasound scan before 24

weeks of gestation (early ultrasound) is for all pregnant women
to estimate gestational age, improve detection of fetal
anomalies and multiple pregnancies, placentation, reduce
induction of labor for post term pregnancy, and improve a
woman’s pregnancy experience.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 82
 Second contact
• Review the history, physical findings and laboratory results at first
contact
• Ask about fetal movement
• Enquire about any complaint or concern
• Determine the gestational age
• Observe her general appearance
• Measure blood pressure
• Measure weight check for weight gain
• Look for pallor
• Measure arm for acute malnutrition screening using MUAC
• Measure the uterine fundal height
• Listen for fetal heartbeat
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 83
 Con’t…
• Perform ultrasound scanning
• Initiate iron-folate and calcium supplementation and
counsel on adherence
• Provide preventive chemotherapy(deworming)
• Check for other danger signs and symptoms
• Assess feeding practices and counsel on optimal
maternal nutrition; extra meal/feeding frequency, diet
diversity, including fruit and vegetables, animal source
feeding
• Assess for mental health and intimate partner violence
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 84
 3 contact
rd

• Conduct same activities as week 20 except for ultrasound scanning

• Conduct urinalysis for proteinuria and urine gram stain
• Test for gestational diabetes for high-risk pregnant women
• Repeat testing for syphilis and HIV if earlier test results are
negative
• Repeat Hb test
• Perform fetal wellbeing assessment if there is a discrepancy
between fundal height and gestational age or if there is a
reduction in fetal movement
• Counsel on birth preparedness and complication readiness
• Counsel on optimal breastfeeding practices
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 85
 4 contact
th

• Repeat all activities done at 30 weeks

• Determine fetal presentation
• Test urine for proteinuria for high-risk women
• Repeat testing for syphilis and HIV if not done
at 30 weeks
• Counsel on breastfeeding and immunization
• Counsel on stimulation for early childhood
development
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 86
 5 contact
th

• Repeat all activities done at 30 weeks

• Determine fetal presentation
• Test urine for proteinuria for high-risk women
• Repeat testing for syphilis and HIV if not done
at 30 weeks
• Counsel on breastfeeding and immunization
• Counsel on stimulation for early childhood
development

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 87

 6 contact
th

• Conduct all activities done at 34 weeks

• Assess mental health
7th contact
• Conduct all activities done at 36 weeks
• Inquire any fears, myths, worries about labor and
delivery
• Repeat Hb test
• Advise the pregnant woman on fetal movement
counting
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 88
 8 contact
th

• Repeat all activities done at 38 weeks

• Review fetal movement counting
• Ultrasound scanning for fetal wellbeing
assessment

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 89

 2.2. 2. INTRAPARTUM CARE...
• It care given for labouring mothers started from
the on set of labour to complete expulsion of
the placenta
• It is the care given by trained providers.
• All women and their birth attendants should be
aware of the need to refer cases of prolonged or
obstructed labour to a higher level of care.
• All institutional deliveries should be monitored
using an appropriately adapted version of a
partograph in order to prevent prolonged labour
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 90
 THE FIVE CLEANS IN DELIVERY CARE
• Clean hands
• Clean delivery surface
• Clean perineum
• Clean cord cutting
• Clean environment

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 91

 Discussion
• What is the advantage of intra partum care
• What complication can you perceived during
the intra partum ?

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 92

 2.2.3. POSTPARTUM CARE
• It is the care given for the mother and new born from birth
to 42 days.
• The main life threatening complications of the postnatal
period include haemorrhage, anaemia, genital trauma,
hypertension, sepsis, urinary tract infections and mastitis.
• All women should receive a post partum visit with in the
first week of delivery in order to ensure early detection
and management of hypertension, haemorrhage and
sepsis.
• However, all women should be assessed with in 24 hours
after delivery.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 93
 Cont… post services
• Management of complications at health
centre or hospital (for example, haemorrhage,
sepsis and eclampsia)
• Promotion and support to breast feeding and
management of breast complications).
• Information and services for family planning.
• STD/HIV prevention and management.
• Tetanus toxoid immunisation

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 94

 Cont… post
NEW BORNC ARE
•Resuscitation
•Prevention and management of hypothermia
•Early and exclusive breast feeding
•Prevention and management of infections
including ophthalmia neonatorum and cord
infections
•Recording of birth weight and referral of new
born for immunisations and growth monitoring
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 95
 2.3. Adolescent reproductive health
definition of adolescent
 WHO - It is a period of;
•Progression from appearance of secondary sex
characteristics (puberty) to sexual and reproductive
maturity
•Transition from childhood to adulthood: involves
physiological, cognitive, social and economic changes
–Development of adult mental processes and adult identity
–Transition from total socioeconomic dependence to
relative independence
• Rapid physiological changes and vulnerability to physical,
psychological and environmental influences
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 96
Major changes during adolescence
• Biological changes – onset of puberty
• Cognitive changes – emergence of more
advanced cognitive abilities
• Emotional changes – self image, intimacy,
relation with adults and peers group
• Social changes – transition into new roles in
the society

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 97

 Age related definitions UN classification

•Adolescence 10 – 19 years
•Early Adolescence 10 – 13 years
•Middle adolescence 14 – 16 years
•Late adolescence 17 – 19 years
•Youth 15 – 24 years
•Young people 10 - 24 years

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 98

 Why ARH?
• Adolescent is critical period in shaping :
–The attitude
–Value
–Behaviors that are carried in to adult hood
•Providers (Planners, managers, decision makers
,administrators ,families) can make the
greatest gain on helping young people
establish life long healthy behavior during
adolescent.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 99
 CONT…WHY?
• More than 1 of every 4 persons worldwide is
between ages 10 and 24 years

• Young people are a great potential resource

for the future, with fresh energy, ideas and
hopes.

• They are at higher risk of reproductive health

problems
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 100
 Cont….
• Problem that occur during adolescent may be
magnifying and require special attention
• Adolescent should be viewed as asset rather than
merely as problems.
–Adolescence is a joyful and creative time during which
future innovators, scientist and leaders are created.
–Adolescents are national and international resources
when they are nurtured appropriately when their
energies are channeled in positive direction.
–They are the window hope to tackle HIV/STI and early
pregnancy
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 101
 Cont… why
• Early marriage and sexual coercion is
abundant in some regions of the world
• Adolescents are forced to become sex workers
in some parts of the world
• Adolescence is a stage where a lot of
biological and psychological changes occur
associated with special risk

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 102

 Why ARH?

Adolescents are at higher risk for STDs and

unwanted pregnancy
Main reasons:
• Non-use or incorrect use of condoms
•Little knowledge of STDs
•Failure to seek treatment
•Multiple partners
•Use of drug and alcohol

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 103

 Major adolescent RH problems
• HIV/AIDS and STIs
• Early marriage and pregnancy
• Unwanted/ unintended pregnancy
• Unsafe abortion
• Sexual Violence

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 104

 Health needs of adolescents
• Motivation and skills to help them postpone
sex and other risks
• Information, skills and technologies for
protection against infections and unplanned
pregnancies
• Counseling for encouraging or motivating
change of risky behaviors
• Information for helping delay and space
pregnancies
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 105
 Cont… needs
• Information and support during pregnancy,
labor/delivery, childcare, nutrition and healthy
lifestyles
• Protection from violence, forced sex or sexual
coercion
• Avoidance of non-healthy traditional “health”
practices

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 106

Factors affecting RH needs of adolescents

• Age
• Marital status
• Gender norms
• Sexual activities
• School status
• Childbearing status
• Rural/urban residence
• Peer pressure
• Cultural/political conditions
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 107
 Adolescent sexual education
General Idea: Not all sex is risky. Experimentation
with sex is normal and developing sexuality is a
natural part of adolescence
•Increased interest in the opposite sex
•Concerns regarding physical and sexual
attractiveness
•Frequently changing relationships
•Rule and limit testing
•Experimentation with sex
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 108
 Sex and developmental needs
• Having sex is pleasurable and can enhance
one’s sense of intimacy with others
• Being sexually active may enhance status in
adolescent peer groups
• Initiation of sexual behavior marks a transition
to more adult behavior
• Having sex may be a way to assert autonomy
from parents

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 109

 What is risky sexual behavior?
• Early initiation of sexual intercourse
• Unprotected intercourse
• Multiple sexual partners
• Sex while under the influence of drugs or
alcohol

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 110

 Factors for risk sexual behavior
• Early onset of puberty
• Substance abuse
• Childhood sexual abuse
• Low parental education
• Low parental monitoring
• Low self-esteem
• Poverty
• Sexually-active peer group
• Perception of sexual activity among cohort
• Media portrayals of sex and sexuality
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 111
 Consequences
• Teen pregnancy
• Low self esteem
• Sexually transmitted infections

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 112

 Protective factors
• Religiosity
• Close parent-child relationship
• Positive parent communication
• Access to condoms and other contraceptives
• Perception of positive peer group attitudes
towards delaying intercourse and/or
contraceptive use
• Access to prevention education
• Access to STI screening, treatment and counseling
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 113
 2.4. INFERTILITY

Discuses what are the causes of infertility in

Group for 10 minutes and present to the
whole class

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 114

2.5. INFERTILITY TREAMENT AND
CONTROL

•Infertility: is defined as the inability of a couple to

conceive after 1 year of frequent unprotected
intercourse without contraception

•Subfertilty : diminished capacity to conceive

•Fecundability: is defined as the probability of

achieving a pregnancy within one menstrual cycle, (in
normal couples the chance of conception after 1
month is approximately 25%).
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 115
 con’t … infertility

•The inability to conceive following unprotected

sexual intercourse for 1 year (age < 35) or 6 months
(age >35)
•Affects 15% of reproductive couples 6.1 million
couples
•Men and women equally affected

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 116

REQUIREMENTS FOR
CONCEPTION
• Production of healthy egg and sperm
• Unblocked tubes that allow sperm to
reach the egg
• The sperms ability to penetrate and
fertilize the egg
• Implantation of the embryo into the
uterus
• Finally a healthy pregnancy

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 117

 Cont… INFERTILITY
• Reproductive age for women
– Generally 15-44 years of age
– Fertility is approximately halved between 37th and 45th
year due to alterations in ovulation
– 20% of women have their first child after age 30
– 1/3 of couples over 35 have fertility problems
• Ovulation decreases
• Health of the egg declines
• With the proper treatment 85% of infertile
couples can expect to have a child.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 118

 TYPES

Types

Primary Secondary
where the difficulty in
couple have conceiving after
never already having
achieved a conceived and
pregnancy carried a normal
pregnancy

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 119

 INFERTILITY: ATTRIBUTING
CAUSES IN

• Female 58%

• Male 25

• Unknown 17%
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 120
 AETIOLOGY OF INFERTILITY
Male factor
• Systemic factor:age above 45 yr, smoking,
alcoholism
• Endocrinopathy:hypothalamic pitutary dysfunction,
hypothyroidism
• Coital difficulty
• Psycological:psychiatric illness
• Immunological:sperm autoagglutination
• Genital: defective spermatogenesis, undescended
testis, hypo spadiasis klinefelter syndrome damage
due to smallpox mumps, hydrocele
• MayGenital
26, 2025 duct obstruction and
by G/hiwot G/mariam( infection
Assistant Prof 121
 FEMALE FACTOR
• Systemic factor : age, obesity,
• Psycological factor:fear of sex marital dysfunction

• Endocrino pathy:thyroid disorder cause infertility

through an ovulation
• Genital factor: vaginal factor, cervical factor,
anatomical defect
In approximately 20% of couples,
the cause remains unknown and is
classified as unexplained infertility.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 122

Female factor infertility can be divided into several categories

• Cervical factor infertility

• Uterine factor infertility
• Ovarian factor infertility
• Tubal factor infertility
Cervical factor infertility
• Account for 5-10% of infertility
• Can be caused by :
o Cervical stenosis
o Abnormalities of the mucus-sperm interaction
o Anti-sperm antibodies
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 123
 Uterine factor infertility
• May be associated with primary infertility or
with pregnancy wastage and premature
delivery.
• Uterine factors can be congenital or acquired.
• They may affect the endometrium or
myometrium and are responsible for 2- 5% of
infertility cases.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 124

 Congenital defects
The full spectrum of congenital/mullerian abnormalities varies
from:
• Total absence of the uterus and vagina to minor defects
such as arcuate uterus and vaginal septa (transverse or
longitudinal)
• Premature delivery has been associated with cervical
incompetence.
• Septate uterus may also be responsible for implantation
problems and first trimester miscarriages.
• Placental polyps may develop from placental remains.
• Intrauterine and sub mucosal fibroids are very common,
affecting 25-50% of women.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 125
 Tubal factors infertility
• Abnormalities or damage to the fallopian tube
interferes with fertility and is responsible for
abnormal implantation (e.g. ectopic
pregnancy)
• Other tubal factors associated with infertility
are either congenital or acquired.
• Congenital absence of the fallopian tubes can
be due to spontaneous torsion in utero
followed by necrosis and re absorption.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 126
 COMBINED MALE AND FEMALE
FACTOR

• Inadequate sperm production

• Failure of ovulation
• Abnormility in female genital tract

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 127

 Management of infertility
Treatment for men
• General sexual problems: addressing impotence
or premature ejaculation can improve infertility.
• Treatment for this problems often is with
medication or behavioral approaches.
• Lack of sperm: surgery or hormones to correct
the problem or use of assisted reproductive
technology is sometimes possible.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 128

 Treatments for women
• drug treatment
• These medications regulate or induce
ovulation, and work like natural hormones to
trigger ovulation such as: follicular stimulating
hormone (FSH) and luteinizing hormone (LH).

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 129

 Commonly used fertility drugs include
 Clomiphene citrate (clomid, seropene)
• Taken orally and stimulates ovulation in
women who have ovulatory disorders.
It causes the pituitary gland to release more FSH
and LH, which stimulate the growth of an
ovarian follicle containing an egg.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 130

 Cont….drugs
 Human menopausal gonadotropin, or hMG
(repronex)
• This is the injected medication for women who
do not ovulate on their own due to the failure
of the pituitary gland to stimulate ovulation.
• Unlike clomiphene, which stimulates the
pituitary gland, hMG and other gonadotropins
directly stimulate the ovaries.
• This drug contains both FSH and LH.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 131
Assisted Reproductive Technologies: In Vitro Fertilization & Related
Techniques

• Assisted reproductive technologies (ART)

include many techniques that allow gamete
manipulation outside the body, and have
evolved greatly over the past two decades

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 132

 In Vitro Fertilization
• In vitro fertilization (IVF) involves the removal
of eggs from the ovary, fertilizing them in the
laboratory, and replacing them in the patient's
uterus.
• The first live birth resulting from this
technique occurred in June 1978.
• Since then, thousands of children have been
born throughout the world.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 133

 Cont..inv
• The success rate in IVF has been improved by
replacing more than 1 embryo, but doing so
increases the likelihood of multiple gestations.
• Among the 31,348 pregnancies that resulted from
fresh non donor cycles in 2002, 54.1% were
singletons, 28.1% were twins, and the rest were
triplets or more.
• Although multiple gestations are often welcomed
by the infertility couples, they are riskier
pregnancies that often result in preterm births.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 134
 Indications for IVF include
• male factor infertility,
• tubal disease,
• decreased ovarian reserve,
• endometriosis,
• genetic diseases with need for genetic testing
of the embryos,
• need for third-party reproduction-donor eggs or
gestational surrogate, and unexplained
infertility Technique
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 135
 Embryo Culture
• Embryos are incubated in an atmosphere of 5%
carbon dioxide.
• Various culture media are used and are often
supplemented with either the patient's serum or
synthetic albumin as well as essential and
nonessential amino acids and sugars.
• At various intervals after the attempted
fertilization, the embryos are examined in order to
identify pronuclei, which confirm fertilization, as
well as the stage of cleavage.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 136
 Embryo Transfer
• After 3–5 days of laboratory culture, the embryos
are replaced into the patient's uterus, a
procedure named embryo transfer.
• Prior to transfer, the embryos are graded from A
to D depending on their appearance and on the
degree of fragmentation
• If day 5 or 6 transfers are performed, the
embryos are at the blastocyst stage.
• The decision to transfer on day 3 or 5 depends on
the success rates of the lab and the physicians
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 137
 Cont…
• The decision of how many embryos to transfer
is done by the patient in conjunction with the
physician and the embryologist in conjunction
with the American Society for Reproductive
Medicine (ASRM) recommendations based on
the patient's age

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 138

 2.5. STI/HIV/AIDS management
STI transmission dynamics at population level
General population

Bridging population

Core
transmitters

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 139

 How STIs disseminate?

Basic Reproductive
rate

Ro = B x c x D
Transmission Rate of Duration
efficiency sex partner of
change infectiousness

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 140

 The Transmission of STIs
• The most common mode of transmission is
unprotected sex

• Other forms of transmission are

– Mother to child
• During pregnancy (HIV & syphillis)
• At delivery (gonorrhea ,chlamydia &HIV)
• Through breast feeding
• Unsafe (unsterile ) use of needles or injections
• or contact with blood or blood products (syphilis
, HIV &hepatitis )
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 141
 SYNDROMIC MANAGEMENT OF STIs
• Etiologic diagnosis – using lab to identify the
causative agent
• Clinical diagnosis –using clinical experience to
identify causative agent.
Etiologic management
• Advantages:-
 Avoids over treatment
 Conforms to traditional clinical training
 Satisfies patients who feel not properly attended
 Can be extended as screening for the asymptomatics
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 142
 Problems of etiologic approach
• Requires skilled personnel & consistent supplies
• Treatment does not begin until results are available
• It is time consuming & expensive
• Testing facilities are not available at primary level
• Some bacteria fastidious &difficult to culture
(H.ducrey, C.trachomatis)
• Lab. results often not reliable
• Mixed infections often overlooked
• Miss-treated/untreated infections can lead to
complications and continued transmission
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 143
 Clinical Management
• Advantages:-
Saves time for patients
Reduces laboratory expenses
• Disadvantages:-
Requires high clinical acumen
Most STIs cause similar symptoms
Mixed infections are common &failure to treat
may lead to serious complications
Doesn’t identify asymtomatic STIs

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 144

 Syndromic Approach
• Syndrome – is group of symptoms patient
complains & clinical signs you observe during
examination
• Different organisms that cause STIs give rise to
only limited number of syndromes
• There are seven syndromes (aim is to identify
&manage accordingly)

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 145

 Identifying syndromes
SYNDROME MOST COMMON CAUSE

Vaginal discharge Vaginitis(trichomniasis, candidisis)

Cervicitis(gonorrhea, chlamydia)

Urethral discharge in men Gonorrhea, chlamydia

Genital ulcer Syphilis, chancroid, herpes

Lower abdominal pain Gonorrhea, chlamydia, mixed

anaerobes
Scrotal swelling Gonorrhea, chlamydia

Inguinal bubo LGV, Chancroid

Neonatal conjuctivitis Gonorrhea, chlamydia

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 146

 Advantage of syndromic management
• STI sign and symptoms are rarely specific to a
particular causative agent
• Laboratories are either non-existent or non
functional due to lack of resources
• Dual infections are quite common and both
clinician and laboratory may miss one of them
• Waiting time for lab. results may discourage
some patients
• Failure of cure at first contact
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 147
 Limitations of syndromic management
• Misses sub-clinical infection

• Needs validation study

– Require prior research to determine the common
causes of particular syndromes

• Needs training

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 148

 STI syndromes
• The commonly encountered STI syndromes
are:
– Vaginal discharge
– Urethral discharge in men
– Genital ulcer
– Lower abdominal pain in women
– Inguinal bubo
– Scrotal swelling
– Neonatal conjunctivitis.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 149
 The relation ship between STI and HIV AIDS

• The relationship between STIs and HIV/transmission has been

described as an epidemiological synergy and share the
same risk factors.
1. STIs enhance the sexual transmission of HIV through:
• Disrupting integrity of the skin barrier
• The presence of genital ulcers is known to increase the
risk of HIV transmission 3-5 folds
• Inducing inflammation
• Increasing viral shedding

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 150

 The relation ship b/n STI and HIV AIDS …..

2. HIV infection affects STIs through:

• Increased susceptibility to STIs among immuno

suppressed individuals

• Altering susceptibility of STI pathogens to antibiotics

→decreasing effectiveness of treatment. (This has been
reported for chancroid and syphilis)

• The clinical features of various types of STIs are

influenced by co-infection with HIV.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 151
 The Main Aims of STIs Prevention & Control are:-
Interrupting the transmission of STIs
• Prevent development of disease and complications
• Reducing the risk of acquiring and transmitting HIV
Prevention and Control of STIs Involves
• Promotion of safer sexual behavior
• Promotion of health care-seeking behavior
• Early diagnosis and treatment
• Targeting vulnerable groups

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 152

 2.6. Family planning
Objective: at the end of this topic students will
be able to
 Definition of family planning
 Scoops of family planning
 Strategies of family planning
 Types of contraceptives

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 153

 Demographic Transition
• Stage I (pre transition): high birth rate and death rate
(constant/slow growth, traditional society)
– Famine, wars and epidemics
• Stage II and III (transition): 1st fall in death rate, rapid
growth and then decline in birth rate slow growth
(improvements in health)
– Better hygiene, public sanitation, improved nutrition
• Stage IV (post transition): low birth rate (delayed
marriage, widespread contraception) low death rate
– Delay age at marriage, urbanization, industrialization

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 154

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 155
 Different Views

– Population persimists
• High fertility and rapid population growth inhibit
development
– Optimists
• Rapid population growth and large population
size can promote economic prosperity
(abundant human and intellectual capital,
increase market size)
– Population neutralism
• Little evidence that population growth by itself
affects economic performance
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 156
 Strategies to control rapid population growth

• Strengthen family planning programs

• Emphasize human development (education,
gender equality, and child health)
• Encourage delays in child bearing (invest in girls
education)

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 157

 Family planning
Definition
• Having the number of children you
want when you want them
• It is not only to control births, but to
plan pregnancies

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 158

 Why family planning (rationale)
Family Planning has been one of the
key public health interventions and a
component of international
development assistance:
– Demographic (late 1960s and 70s)
• Population growth as a threat to food
supplies and natural resources
– Health (1980s)
• Consequences of high fertility on maternal,
infant and child morbidity and mortality
– Human rights (1990s)
• Women's rights
• Reproductive right
May 26, 2025
• Reproductive health of men and women
by G/hiwot G/mariam( Assistant Prof 159
 Demographic rationale
• Objectives of interventions at that
time were:
– Reducing high fertility rate
– Lower population growth
– Improve living standards
– Less impact on natural resources and
the environment

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 160

 Health Rationale(1980s)
• High rates of maternal, infant
and child mortality required
attention
1. Avoiding the extremes of
maternal age (<15, >35 years)
for child birth
– Older
• Mal-presentations, uterine rupture,
hemorrhage, abnormal placenta…
– Young
• Pregnancy induced hypertension, obstructed
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 161
labor…
 Health Rationale
2. Decreasing risk by decreasing
parity
3. Preventing high risk pregnancies
(previous complications, chronic
diseases, anemia…)
4. Decreasing abortion risks “every
child a wanted child”
5. Non contraceptive benefits
(Protection against STIs and
reproductive tract cancers)
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 162
 Health Rationale
6. Benefits to children's health
a. Contributes to reducing maternal
mortality
b. Infants born at least 24 months after
the previous birth have lower mortality
c. Children of teenagers are more likely
to die
d. Children of older mothers are more
likely to be born with congenital
abnormalities
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 163
 Human rights rationale
• UN on Human rights day December 1967
– “That the great majority of parents desire to
have the knowledge and the means to plan their
families ; that the opportunity to decide the
number of and spacing of their children is a
basic human right”
• Teheran Conference on Human Rights 1968
– Affirmed the basic right of couples to decide on
the number and spacing of their children
• The 1994 ICPD has resulted major shift
toward reproductive rights
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 164
 Contraceptive Methods
• Refers to methods or ways by which unwanted
pregnancy is prevented
• Not all these methods are equally effective,
safe or equally acceptable
• Therefore, individualization of contraceptive
choice is important for successful prevention
of pregnancy

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 165

 Methods of contraception
• Traditional
– Withdrawal(Coitus interuptus)
– absteinece
– Calendar
– Basal body temprature
– Biling
– Symthotermal
• Modern
– Permanent
• Female sterilization (tubectomy/tubal ligation)
• Male sterilization (vasectomy)
– Nonpermanent
• Condoms, pills, injectables, implants, mucus, IUD…

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 166

 Non permanent methods
Non-intercourse Intercourse related
related
– Barriers physical
– Hormonal: OC, (condom/diaphra
injectables, gm) or chemical
implants (spermicides)
– Natural
– Non-hormonal:
– Post-coital
intrauterine
devices (medicated
methods
or non medicated)
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 167
 Family Planning Interventions areas
• Health Facility
– Public
– NGO
– Private for-profit
• Social marketing
– DKT
• Community
– CBD
– CBRH
– Marketplace
– Workplace

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 168

 Facility Based Community Based
Public
Health post
Health center
HEWs
Hospital etc.

Referral

Marketplace
NGO
FGAE
MSIE
FBOs etc
Referral
CBRHAs
Referral

Private for-profit Workplace

Higher
Lower
Medium Youth
Hospital etc.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 169

3. Maternal Health: Family Planning (FP)
40 Contraceptive Prevalence Rate (CPR) % 35.3 35.2
30 27 Ethiopia
21
20 14 16 Tigray
10 6 9
0
EDHS2000 EDHS2005 EDHS2011 EDHS2016

60 CPR (%), EDHS 2016 Target: 55%

50 50 47 (National STP)
40
40 35 35 National Average: 35%
30 29 29 28 28
20
12
10
1
-
A ra NP ay ela eri D uz i ya fa
r al
i
A a r b r D
h SN Ti
g a um m A om
A
m am H / G ro S
May 26, 2025 G G/hiwot G/mariam( Assistant Prof
by B O 170
3. Maternal Health: FP . . .
• The CPR in
Tigray is similar Type of FP Method and Unmet
30 Need, EDHS 2016
with the national
Average (35%) in 23 22
EDHS2016 20 19 18
• The Unmet need
in Tigray is less 11
10 8
than the national
average (18% Vs 4
2 2 1
22%) 0
Injectable Implants Pills IUD Unmet
Need

Ethiopia Tigray

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 171

3. Maternal Health: TFR
• The average
Total Fertlity Rate (TFR)
number of 6
5.9 5.8
children a women 5.4
5.1
5 4.8 4.6 4.6
can have in her
reproductive age 4
group Target: 3
3
• Tigray is (National HSTP
relatively lower 2
than the national 1
average (2000,
0
2005, and 2011, but EDHS2000 EDHS2005 EDHS2011 EDHS2016
EDHS2016 do not
show by regions yet)
Ethiopia Tigray

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 172

 Factors influencing FP Service Delivery
• Barriers to using FP come from individual /
cultural attitudes, service delivery issues, and
medical practice / policy limitations.
1. Socio -cultural ;
 Community norms about FP
 Women’s autonomy
Fears /rumors/myths
Cultural and religious practice

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 173

 Factors influencing Service…
2 Physical access
 Time
 Distance
 difficulty getting there
3 Clients perception about
 Effectiveness
 Cost
 Knowledge

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 174

 Factors influencing Service cont…
4 Presences of competing need
 Child care
 Work , Food , Fire wood
5 quality and access
 Method choice and availability
 Length of waiting time
 Medical bureaucratic barriers
 Interpersonal relation
 effective counseling
 Continuity of care
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 175
 Factors influencing Service…

6 Political Environment
 Lack of political support and commitment
 Unfavourable policies
 Unfavourable legal issues

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 176

 Possible solutions
• Awareness creation and community
mobilization
• Encourage male involvement
• Improve quality of the service
• Improve service accessibility
• Encourage participation of community members
including community and religious leaders
• Strengthening women empowerment

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 177

 Possible solutions cont…
• Linking FP with other services
• Enforcing governments to set appropriate
political commitment.
• Set appropriate time for FP services
• Strengthening CBD, social market and out
reach activities.
• The government should give emphasis to
allocate budget for FP
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 178
 2.7. ABORTION

Objective: at the end of this topic students will be

able to
 Know definition of abortion
 Stages of abortion
 Types of abortion
 Management of abortion
 Stragies to prevent abortion

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 179

DEFINTION:
Initiation of termination of pregnancy/expulsion
or termination of the fetus before it gets
viable
• 20 weeks /<500gm= in USA
• 28 weeks/ < 1000gm =Ethiopia
• 24 weeks =UK

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 180

Magnitude
• 25 % patients will come with the compliant of
vaginal bleeding and/or pain
• Abortion is common cause of vaginal bleeding
during the 1st/2nd trimester pregnancy
• One of the five leading causes of maternal death
• World wide about 46 million (22%) end in
abortion
• 20 million are unsafe
• Death of abortion is 200/day, even more suffer
from serious ( often permanent) disabilities
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 181
 Cont…

• 95 % of this death occur in developing countries

• Africa contributes 11% of women but 50% of all
maternal death
• In Ethiopia abortion accounts for about 25-50% of
maternal death
• 5th cause of admission
• Majority of the cause of death is from sepsis/ shock
• Double failure =unable to prevent unwanted &
unplanned abortion and unable to manage
complications of abortion
• All this deaths and its complication are preventable
if proper management
May 26, 2025
of abortion is provided
by G/hiwot G/mariam( Assistant Prof 182
 In Ethiopia
 it is estimated that there are 3.27 million
pregnancies every year of which approximately
500,000 end in either spontaneous or unsafely
induced abortion.
WHO characterizes unsafe abortion by the lack
of skilled providers, safe techniques, and/or
sanitary facilities.
Unsafe abortion is the commonest cause of
maternal mortality accounting for up to 32% of
all maternal deaths in Ethiopia.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 183

Abortion-related morbidities and mortalities
• Unsafe abortion is a global problem.
• Millions of women around the world risk their
lives and health to end an unwanted pregnancy.
• Every day, 55, 000 unsafe abortions take place–
95 % of them in developing countries-and lead
to the deaths of more than 200 women daily.
Globally, one unsafe abortion takes place for
every seven births.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 184

Classification
Occurrence
1.spontaneous
-no intervention
-10-15 % of all pregnancies
-1st trimester =chromosomal abnormality,2nd
trimester structural abnormality
2. induced
• Surgical or medical intervention
• Can be safe /unsafe
• Safe can be therapeutic or unwanted pregnancy
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 185
Clinical stages
Threatened :
• Mild bleeding, mild lower abdominal pain,
closed cervix, alive fetus, high chance of
continuing the pregnancy
Inevitable:
• No chance of continuing the pregnancy,
variable amount of vaginal bleeding, cramp
lower abdominal, vxal bleeding, cervix open,
no passage of conceptus products

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 186

Incomplete abortion:
• part of the conceptus tissue is expelled, cx
open, continued bleeding
Complete abortion:
• complete expulsion of conceptus tissue,
bleeding stopped, cervix closed, small uterus,
not possible to tell before 14-16 weeks

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 187

Missed abortion
• Fetus dies in utero & retained
• History to threatened abortion
• Brownish vaginal discharge
• Regression of all pregnancy symptoms
• Cessation of fetal movement
• Failure of growth of uterus
• HCG +/-, but become –ve after 8 weeks

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 188

• What are the complications of
abortion ?

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 189

Complications of abortion
-Bleeding (anemia, shock), Infection (sepsis,
pelvic inflammatory disease), chronic pelvic
pain
-Infertility ectopic pregnancy Dysmennores,
-Uterine perforation, Intra abdominal injury,
cervical laceration
-Cervical stenosis/incompetence
-Transfusion related complications,
Psychological& Socioeconomic

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 190

Risk factors of abortion:
No use of family planning
Family planning failure
Rape
Lack of control over contraception
 Young age or single marital status
 Abandonment or unstable relationship
Mental or physical health problems
Severe malformation of the fetus
Financial constraints
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 191
Emergency treatment of abortion (incomplete abortion)
and potentially life threatening complications
• Rapid assessment & diagnosis of the cases and timely
management is the most crucial step in preventing
maternal death
Diagnosis
-Hx:
-Objective
1) Identify preexisting conditions that affect treatment
(drug allergy, HIV, heart diseases)
2) Life threatening conditions (shock, hemorrhage, sepsis
& organ damage )
3) Determine causes of abortion
-specific informationby G/hiwot G/mariam( Assistant Prof
May 26, 2025 192
HX
*Vaginal bleeding, duration amount
*Crampy abdominal pain /lower abdominal pain
=duration and severity
* Amenorrhea =Length of amenorrhea,
* Abdominal /shoulder pain =indicates intra
abdominal injury
*contraceptive hx
*fainting
* Drug allergy
* History of interference and method of employed
*MaySymptoms
26, 2025
of infection =fever, chills
by G/hiwot G/mariam( Assistant Prof 193
P/E
Objective
* General state
* Presence of complications (shock,hemorrhage,
sepsis, intra abdominal injury, genital trauma,
& uterine perforation)
* Evaluate the size of the uterus
* Assess the status of the cervix
* Stage of abortion

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 194

-specific information
*V/s, general health of the patient
*General systemic examination
*Abdominal examination:
• distention, movement with respiration,
bowel sound, location and severity of the
tenderness and rebound tenderness, uterus
size, masses, shifting dullness

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 195

cont…
*pelvic examination ( speculum and digital );
conceptus tissue in the vagina or cervical
canal, amount of bleeding and presence of
offensive discharge ,extent of cervical
dilatation and presence of cervical excitation
tenderness ,size, position & consistency of the
uterus ,adenexial mass & other pelvic
masses ,cervical laceration

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 196

 Lab TESTS:
• HCT-hematocrit to diagnose anemia
• BG –blood group
• WBC –white blood count
• ESR - ertrocyte sedimentation rate
• U/A – urine analysis
• RFT –renal function test
• LFT – liver function test
• plain abdominal X-ray
• U/S –ultra sound
• HCG- homan corion gonadtophin hormon
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 197
MANGMENT
Principles
-Rx life threatening conditions = shock, sever
anemia & sepsis and intra abdominal injury
-Specific management to the stage of
abortion
• All abortions except uncomplicated
threatened abortion & sure of complete
abortion needs evacuation
- Appropriate & timely referral

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 198

A. evacuation (E)
*method of evacuation=
• MVA(manual vacuum aspiration)= easy, quick, less
complications), for GA(gestational age) of <12 -14
weeks
• Sign of completeness (gritting sound, cervix tightly
grasp the cannula, bright red frothy blood, no tissue
coming)
• problems =full syringe, cannula with draw prematurely,
clogged cannula, no vacuum, incomplete evacuation
E & C =can be used for all GA
Medical methods =safe abortion, inevitable abortion,
Includes ( oxytoxine, misoprostone, mefipristone)
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 199
After the procedure:
inform her
-Mild back and supra pubic pain
-Some bleeding which stops after 3-5 days
-Avoid coitus until 3 days after bleeding stops
-Inform danger signs =Prolonged bleeding,
foul smelling discharge, sever abdominal pain,
vomiting,
-Avoid tight under wear till bleeding stopped

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 200

1. Threatened;
Bed rest, sedatives
Admission = severely bleed, bad obstetric Hx,
from remote, night presentation
Avoid intercourse
U/S
Monitor progress
Evacuation if there is sign of infection
provide prophylaxis antibiotics

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 201

2. Complete
If completeness is assured =
Erigometrine, antibiotics if there are indications
If completeness can not be assured (early
pregnancy, expulsion out side health
institution, no u/s) =evacuation

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 202

3. Inevitable abortion
 < 14 weeks =evacuation (MVA)
Mandatory for removal are =
• Sever bleeding, Bleeding that lasts more than 24 hrs
• Presence of remained parts of the placenta and
concepts on vx examination
 > 14 weeks =
-Admission and monitor v/s and amount of bleeding
-Evacuation after expulsion of the fetus /or part of the
placenta
-oxytoxine drip followed by Evacuation after expulsion
of the fetus
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 203
 4. Incomplete
< 14 weeks =MVA, E & C,
-> 14 weeks = E& C, D & E (oxytoxine infusion
5. Missed abortion
-expectant = till 4 weeks,
 Evacuation if it is > 4 weeks
evacuation if she develops coagulation
derangement in between aggressive = evacuation
• D& C =if ux is < 12 weeks
• Pitting/oxitoxic drip > 12 weeks
• NB: D =dilatation, C =curettage
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 204
B. Management of complications
1. Sever hemorrhage
Dx: degree of bleeding =clotted, massive bright red
bleeding that soaks under wear /other clothes. Change
in consciousness, slurred speech, deranged V/S, pale
conjunctiva, dry tongue & buccal mucosa,cold &
clammy skin, rigid abdomen, full flank, + shifting
dullness

Mx: open IV, draw blood for HCT, BG & cross match, fast
fluid replacement, record B/P frequently, administer
O2, shock position, warm, and monitor U/O (urine out
put)
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 205
2. Uterine perforation
Signs
-Instrument extends beyond the expected limit of the
uterus
-Fat /bowel removed from the uterus
-Sever pain and continuous bright red bleeding
-In apparent v/s derangement
Mx
-Stabilize the patient; don’t give any thing per os
-Monitor V/S ,take blood for HCT and BG
-Start broad spectrum antibiotics
Evacuation is completed
-Give erigometrine 0.5 mg
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 206
-Observe for 2 hours
Cont…
• If stable and bleeding stops= give erigometrine and
continue over night observation
• If bleeding doesn’t stopped and there is V/S
derangement emergency laparotomy is performed
Evacuation not completed
 Laparotomy & complete under direct vision
 Repair / hysterectomy can be done after laparotomy
Indication for laparotomy in perforated ux
– unstable V/S
– uncontrolled sepsis
– incomplete evacuation
– associated bowel injury
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 207
3. Intra abdominal injury
Ssx;
---nausea, vomiting, shoulder pain, fever,
crappy abdominal pain
---Distended abdomen, decreased bowel
sound, tense & hard abdomen, rebound
tenderness
Mx; resuscitation and IV antibiotics
Laparotomy (refer to place where laparotomy
could be done

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 208

 4. Sepsis
Etiology =poly microbial
Ssx
Fever, chills, rigor, Hx of interference, prolonged
bleeding, abdominal pain, vx discharge, and
change in mental status prolonged arrival to
hospital after the onset of symptoms
Foul smelling discharge, distended abdomen,
tenderness, low BP ,T > 38 degree centigrade,
PR>100 pulses per minute, RR> 18 breath per
minute, cx motion tenderness, adenexial
tenderness
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 209
Post abortion care (PAC)
o This is global strategy designed to reduce MR and MB
occurring as a result of unsafe abortion & its
complications.
o It has 5 components
 Emergency treatment of abortion (incomplete
abortion) and potentially life threatening
complications
 Post-abortion family planning counseling and services
 Links between post abortion emergency services and
the reproductive health care system.
 Community service provider partnership
 Counseling
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 210
Grounds on Which Abortion is Permitted, revised
abortion law of Ethiopia, (House of Parliament,
2005)
• When the pregnancy puts the woman’s life at risk
• Fetal impairment or deformity
• When pregnancy follows Rape or incest (based
on the woman’s complaint only)
• When pregnancy occurs in minors (stated
maternal age <18 years)
• The woman is physically and mentally unable to
care for the would-be born child
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 211
 2.9.HARMFUL TRADITIONAL PRACTICES

Introduction
• Harmful traditional practices are
known to affect adversely the health
of people, the goals of equality, the
political, and social rights, and the
process of economic development.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 212

 Common harmful traditional practices
in Ethiopia

Female Genital Mutilation

Early Marriage
Marriage by Abduction
Uvelectomy
Milk Teeth Extraction
Food Prohibition.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 213

 I. Female Genital Mutilation(FGM)
 Defn. FGM involves removal of parts or
the whole external genitalia of females.
 origin
It’s believed that FGM was practiced in
the ancient Egypt.
Hx shows the existence of FGM in the pre
Islamic Arabia, ancient Rome & Tsarist
Russia.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 214

 Cont…
 FGM & religion
oBoth Muslims and Christians in African
countries practiced FGM.
oThe origin of FGM predates Islam and
Christianity while it continues to take its
largely in Africa.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 215

 Types of FGM

Type I – Cltoridoectomy
Dissection and removal of fore skin of the clitoris
Removal of the whole clitoris
Is more practiced in Egypt ,Ethiopia, Gambia ,Sudan and
Nigeria.
Type II – Excision
Total removal of clitoris, partial or total removal of the labia
minora without closure of the vulva.
The most common type in Africa ,which is practiced in more
than 20 countries

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 216

 Cont…
Type III – Infibulations(pharaonic
circumcision)
Clitoris,labia minora and inner walls of
labia majora are removed ,the two labia
are joined to seal except small opening to
permit urination and and menses.
Infibulations is practiced in Djibouti, Egypt, some
parts of Ethiopia, Mali, Somalia and the northern
part of the Sudan.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 217

 Scope of FGM in Ethiopia

About 24% of Ethiopians undergo one of the three forms .

Type I: practiced by the amharas, muslims of Tigray called

Jeberti.

Type II: practiced by the Gurages, Tigrey, Oromos, Shankilas &

Kunamas

Type III or infibulations: Is more common in ethnic Harari,

Somali, Mensa, Saho, Billen, Issa,Afar &Some Oromos In

Hararge.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 218

 Cont…
Age at which FGM is performed varies from one area to
another area.
FGM is performed on infants as young as a few days
old, on children from 7 to 10 years old, and on
adolescents.
Adult women also undergo the operation a few days
before marriage.
In Ethiopia it’s commonly practiced during infancy
childhood or before puberty.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 219
 Cont…

It is usually done under unhygienic

conditions by TBA or traditional healers
with instruments such as razor, a piece of
glass or locally available material and the
instruments used are crude and unsterilized .

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 220

 Consequences of FGM
Acute Cx
• Haemorrhage
• Pain
• Infection and septicaemia
• Tetanus
• Injury to surrounding tissues
• Retention of urine

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 221

 Delayed and Long Term Cx

Sexual problems- Dysmenorrhea

dysparunia
Infertility
Fistula - RVF/VVF
Prolonged labour Urinary tract
/obstructed labour problems-UTI
Still births, foetal
distress as a result Narrowed
of OL due to vaginal opening
obliterated lower
birth canal. Ugly scar
formation

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 222

 Cont..
• FGM is a custom or tradition synthesized over time from
various values, especially religious and cultural values.
• The reasons for maintaining the practice include religion,
custom, decreasing the sexual desire of women, hygiene,
aesthetics, facilitation of sexual relations, fertility,
virginity,etc.
• In general, it can be said that those who preserve the
practice are largely women who live in traditional societies in
rural areas.
• Most of these women follow tradition passively.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 223

 Cont…
• The underlying reasons could be summarized as
economic vulnerability of women and their
dependence on marriage for survival as well as
ignorance about the functions of their body.
• Ignorance is a major factor for the persistence of
the practice.
• Parents subject their children to FGM with the best
intentions not knowing a better alternative to
marriage.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 224
 II. Early Marriage (EM)
• Early and forced marriage as practiced in some
countries of Asia and Africa leads to girls as young as 7
years to marry older man.
• It has been a common practice, particularly in much of
rural Ethiopia to get girls married at an early age as 10
– 15.
• It has devastating effect on child, family and
community.
• It is parent centred marriage between two families
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 225
 Justification given:
Competition to find in-laws who has family
status
Security for the future-while parents are
young/alive
Conformity-conform to tradition----’koma
kerech’
Ensure virginity /avoiding premarital sex

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 226

 Cont…
Fertility-many children, grandchildren means
security
Material benefit-access to livestock,
land,dowry,etc..
Others-marry before menses, fame of
ceremony, service of soon in law and fear of
abduction.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 227

 Scope of EM in Ethiopia
• Esp. in the north marriage could take place as early as 7
yrs

• In Wollo 22% marry at the age 10-14yrs, in Gojjam it’s 30%

and in Gondar the preferred age at marriage is 12.7yrs.

• Legally EM is banned by national and international laws.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 228

 Cont…
Health related problems of EM
- Sexual abuse, physical abuse
- Early pregnancy, child rearing, unwanted
pregnancy
- Maternal morbidity—fistula
- Maternal mortality-heamorage,
- Obstructed labor

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 229

 Cont…
Social impact of EM
- Denied education & own choices
- Urban migration
- Fistula pts avoided by husbands & the
society
- Psychological trauma from the 1st sexual
experience
- Many children

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 230

 III.Marriage by abduction

• It’s defined as unlawful kidnapping or

carrying away a girl for marriage.
• In almost all cases rape follows it.
• It’s a civil offence by Ethiopian law.
• A gross violation of women’s rights.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 231

 Cont…
• Abduction is a well known traditional practice
in parts of Ethiopia whereby girls are
kidnapped and raped to be forcefully married.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 232

 Reasons given for Abduction
• Fear of rejection by the bride’s family
• Avoid excessive wedding ceremony
expenses i.e. too high dowry
• Presence of rival- Outsmarting rivals when the girl has
many suitors and/or the inclinations of the girl or her parents are
not predictable
• Avoiding wedding ceremony-fear of high
cost
• Status difference
• Voluntary abduction, the girl agrees to go
with the man.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 233

 Consequences of abduction
• Health related
- Psychological and physical trauma
- Risk of STIs &HIV
- Unwanted pregnancy and abortions
- Obstructed labor

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 234

 Cont…
Socio economic
 Parents tend to keep their daughters from
school for fear of abduction
 Weak family founded without love
 Forms weak society in general

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 235

 Other harmful traditional practices

• Uvulectomy
prevent problems of feeding (swallowing), avoid noisiness
and improve speech
• milk teeth extraction
prevent diarrhoea and cure various diseases
• Food prohibitions
Certain food items which contain important
nutrients are believed to cause diseases in
women and children.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 236

 Cont…
• Traditional birth practices
-putting cow dung on the umbilical stump.
• Infant feeding traditions.
 Early and late initiation of additional feeds.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 237

 Cont…
N.B. These harmful traditional beliefs and
practices might result in serious health
outcomes including serious bleeding,
acquiring dangerous and fatal infection
and malnutrition

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 238

 Measures to be taken to discourage HTPs
Communication methodologies using both traditional
and modern media .
Programs for religious leaders to demystify
misconceptions.
Alternative employment opportunities for excisors.
Promotion of girls education
Curriculum-RH education in schools
Establishing clubs esp. in schools

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 239

 Cont…
Empowering women.
Advocacy-by decision makers and legislators
Legislative measures-punishing offenders
Training and information to TBAs, community leaders
and to the society.
Counseling at all possible levels
Community participation.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 240

 UNIT THREE

INTRODUCTION HIV/AIDS
AND MTCT

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 241

 HIV/AIDS
• HIV is the virus that causes AIDS. HIV destroys a
certain type of blood cells known as T-cells or CD4
cells that help the body fight off infection, and
gradually weakens the immune system and
exposes to other communicable diseases or cancer.
• HIV has two main species.
 HIV-1 and HIV-2.
• The virus that is wide spread in Ethiopia is the HIV-
1C sub-species.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 242
 Historical Overview of HIV/AIDS in Ethiopia

• 1984: The first evidence of HIV infection in

Ethiopia
• 1986: The first two AIDS cases reported to the
Ministry of Health
• 1989: HIV/AIDS surveillance started
• March, 2005: Free ART program started
• Currently, approximately:
– 129 surveillance sites
– 73 ART sites
– 658 VCT sites
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 243
 HIV IN PREGNANCY
 Is most prevalent in developing countries.
 80% of HIV – infected women are of child
bearing age.
 Prevalence among woman attending ANC
service in East & central Africa is 20-30%(10-
20% in Ethiopia).

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 244

 EFFECTS Of HIV/AIDs ON PREGENANCY
• Spontaneous abortion
• Preterm delivery
• Low birth weight
• Still birth
• MTCT
• Increased maternal morbidity & mortality

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 245

 MOTHER TO CHILD
TRANSMISSION(MTCT)
PERIOD OF TRANSSMISION
• During pregnancy (5-10%)
• During labor and delivery (10-20%)
• During breastfeeding (5-20%)

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 246

 Factors of MTCT
1) General factors – maternal viral load & CD4 counts
_ type of virus( HIV-1 > HIV-2)
_ ARV prophylaxis( reduce by 50%)
_ HAART ( reduce to <2%)
2) Antenatal factors
– prematurity
_ Obstetric procedures(Amniocentesis
_ Obstetric Cxns ( abruptio placenta , Placenta previa)
_ Infections ( malaria , STI)
_ Vitamin A deficiency
_ Sexual behaviour
_ elicit drug use & smoking
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 247
 CONT…
3) Intrapartum factors
– prolonged labour
_ Chorioamnionit
_ prolonged rupture of membrane
_Invasive procedures( internal monitoring, fetal
scalp sampling, operative vaginal deliver &
episiotomy)
_ caesarean section

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 248

 Cont…
4) Breast feeding
_Cracked nipples
_ acute mastitis
_ Breast abscess
_ neonatal oral thrush
_ Mixed feeding
_ Breast Feeding duration > 6months

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 249

 PREVENTION OF MTCT( PMTCT)
Four pronged approach has been developed by
WHO for effective PMTCT. Its components are
as follows

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 250

 Primary prevention of HIV infection

Communication for behaviour change (ABC

approach) to protect reproductive men and
women from becoming infected with HIV and
other STIs
Provide voluntary counselling and testing

services
Promote correct and consistent use of

condoms
Encourage open discussion on reproductive

health issues between parents and their

children
- Early
May 26, 2025 diagnosis and
by G/hiwottreatment
G/mariam( Assistant Prof of STIs 251
Prevention of unintended pregnancies among HIV mothers

• make every child is a wanted child

• Provide family planning counselling
integrated into all potential PMTCT
and VCT service sites.
• The decision is from the patient

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 252

.

Prevention of transmission from infected women to her infant

Ensure availability of antiretroviral drugs and other

appropriate supplies for PMTCT
Provide testing and counselling services integrated

with ANC, labour & delivery and postnatal care

 Safer obstetrical practices
Provide appropriate counselling on infant feeding

and support exclusive breastfeeding

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 253

Treatment, care and support of HIV infected women, their infants and their families

• Provide ART for women with advanced disease

• Provide pregnant women not eligible for ART with
effective PMTCT regimens
• Ensure appropriate follow-up of infants born to
HIV positive women including:
• OI prophylaxis and early infant diagnosis
• Provide HIV testing for family
• Link PMTCT with care and support initiatives
organized for infants and HIV infected women

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 254

 Counseling in MTCT
• Counselling is a therapeutic relationship between
a counsellor and client designed to help a client
reach their goals through well informed choices.
• Counselling in antenatal care presents a unique
situation;
• The women have not attended primarily for
counselling, but for antenatal care.
• Seeking to promote health choices, which
optimize the health of both mother and child.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 255
 COUNSCELING IN THE ANC SETTING
• Group Health education is the main method
of providing IEC.
• PMTCT activities begin with group
education.
• Information is given about HIV/AIDS
prevention, testing, treatment and ARVs.
• Key messages include; HIV, malaria, nutrition
, rest, exercise and childbirth.
• HIV testing will be provided as part of the
package of care after this session
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 256
 Fundamentals of
Counselling
• Informed choice
– If an individual makes an informed decision she takes
ownership .
– She will continue to do so in other areas of care and well
being, both for herself and her child.
• Confidentiality
– To mitigate stigma and avoid possible negative
consequences.
– For the purposes of providing optimal care, this
confidentiality may be extended to other health care
professionals
• Environment
– privacy, enough time , useful job aids.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 257

 Counselling Skills
• Attending
• Active listening
• Probing
• Empathy
• Paraphrasing
• Clarifying
• Reflecting
• Summarising

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 258

 Fundamentals of Post-Test Counselling
• Give the result of the HIV test only when the
client is emotionally ready

• Check what the client understands by the

result

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 259

 WHO recommendations on infant feeding for HIV+
women
• When replacement feeding is acceptable, feasible,
affordable, sustainable and safe, avoidance of all
breastfeeding by HIV-infected mothers is recommended.
• Otherwise, exclusive breastfeeding is recommended
during the first months of life.
• To minimize HIV transmission risk, breastfeeding should
be discontinued as soon as feasible
• Taking into account local circumstances, the individual
woman’s situation and the risks of replacement feeding
(including infections other than HIV and malnutrition).”
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 260
 UNIT FOUR

THE STRATEGIES VENTURED TO MAKE RH

SUCCESSFUL.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 261

 4.1. STRATEGIES
• In seeking to innovate and expand reproductive
health services, programme managers and
policy makers are generally

advised to follow an approach that is

A. public health based – addressing key reproductive health
problems,

B. pragmatic - adding interventions

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 262
 Strategy…
• services in an incremental manner and building on
what already exists, and
c. participatory - recognizing what different actors can
feasibly do
• The need to identify appropriate service delivery
models and subsequently scale-up successful
efforts is acute.
• So in order to provide a quality reproductive
health service, there is crucial part that we
should conceder.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 263

4.2. An integrated approach of reproductive health services

• It is a functional integration which aims at strengthen

linkages b/n closely related areas, there by providing better
quality of care.
Advantage of service integration
 To the client
 Convenient
 Time saving-reduce number of visits
 Complete client needs
 Improve client provider relations
 Increase client satisfaction
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 264
Disadvantage to the clients
• Cost
• Waiting time
• Increase risk of infection
Advantage to provider
• Increase client confidence
Disadvantage to provider
• Heavy work load
• Increase risk of infection

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 265

 Point of integration of components

• Those that can be integrated

• FP/contraception
• RTI
• HIV/AIDS
• MCH
• IEC/BCC

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 266

 When can RH integration occur
– Counseling
– Service provision
– Facility
– Training
– IEC/BCC
– Management
– HMIS/Record Keeping
– Logistics
– Referrals
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 267
 Barriers to RH integration
 FP/RH programs are still weak

 Provider biases and reluctance to address sexuality issues

 Bias against some FP methods e.g. Condoms

 Men and Youth do not utilize the public sector

 High proportion of women are not attended by skilled

provider during delivery
 Stigma
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 268
 4.3. RH INDICATORS
• 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

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 269

 WHO RH Indicators

• Total Fertility Rate

• Contraceptive Prevalence Rate
• Maternal Mortality Ratio
• Antenatal Care coverage
• Skilled birth attendant
• Availability of Basic Essential Obstetric Care
• Availability of Comprehensive Essential Obstetric Care
• Perinatal Mortality Rate
• Low Birth Weight Prevalence
• Syphilis Prevalence
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 270
 CONT… INDICATORS
• Anemia Prevalence
• Abortion among Obstetric Cases
• FGM Prevalence
• Infertility Prevalence
• Urethritis Prevalence
• HIV Prevalence among Pregnant Women
• Knowledge of HIV Prevention Practices
 Sex Ratio at Birth
 Age at Coitarche
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 271
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 (15-49 yrs)
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.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 272

3. Maternal mortality ratio: The number of
maternal deaths per 100 000 live births.
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

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 273

6. Availability of basic essential obstetric care:
Number of facilities with functioning basic
essential obstetric care per 500 000
population.
7. Availability of comprehensive essential
obstetric care: Number of facilities with
functioning comprehensive essential obstetric
care per 500 000 population.
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.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 274
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
(15–49) attending antenatal clinics, whose blood
has been screened for syphilis, with positive
serology for syphilis
11. Prevalence of anaemia in women: Percentage
of women of reproductive age (15–49) screened
for haemoglobin levels with levels below 11
Mg/dl for pregnant women and below 12 mg/dl
for non-pregnant women.
May 26, 2025 by G/hiwot G/mariam( Assistant Prof 275
12. Percentage of obstetric and gynecological
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).
13. Reported prevalence of women with FGM:
Percentage of women interviewed in a
community survey, reporting to have
undergone FGM.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 276

14. Prevalence of infertility in women
•Percentage of women of reproductive age
(15–49) at risk of pregnancy (not pregnant,
sexually active, non-contracepting and non-
lactating) who report trying for a pregnancy
for two years or more.
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.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 277

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.
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.

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 278

 THE END

THANKS FOR SAVING HER!!!

May 26, 2025 by G/hiwot G/mariam( Assistant Prof 279