10 Reproductive health: concepts and issues

Gautam Kshatriya and Nupur Mahajan

Contents

Reproductive health: Concept

• Historical development of the concept of reproductive health
• Development of reproductive health

    Issues regarding Reproductive health

• Reproductive health risks and consequences in adolescents
• Violence against women
• Female genital mutilation
• Early marriage

    Magnitude of reproductive health problems

Reproductive health in developing countries

Interventions for safe reproductive health and child care

Learning objectives:

• To know about the historical development of the concept of reproductive health
• To understand the issues regarding reproductive health
• To know about reproductive health risks and consequences in adolescents
• To comprehend the magnitude of reproductive health issues and the state of reproductive health in developing countries

    Reproductive health: Concept

The World Health Organization defines “Health” as the condition of overall physical, mental and social well-being; and not merely the absence of disease or illness. Furthermore, reproductive health or sexual health is mainly concerned with the reproductive system, their functions and the processes for every stage of life (WHO, 1948). Therefore, reproductive health implies that individuals are capable to have a safe, responsible and satisfying sexual life; have the competence to reproduce and the choice to make a decision if, when and how frequently they want to do so (ICPD Program of Action, 1994). The concept of reproductive health also coupled the integration of the right of men and women to be educated about steps for safe sex and providing them easy access to secure, effective, and reasonably priced methods of fertility guideline of their own wish, and the right of usage of apposite health care facilities that will help women to be safe and protected throughout pregnancy and childbirth and provide couples with the efficient chances of having healthy infants (WHO, 1988). Reproductive health, therefore, refers to the diseases, illness, and disorders which affect the functioning and performance of male and female reproductive systems throughout life. Reproductive disorders consist of birth defects, developmental disorders, low birth weight, premature birth, infertility, impotency, and menstrual dysfunctions (NIH, 2015).

Reproductive health as a concept was first discussed at the International Conference on Population and Development (ICPD) held at Cairo in 1994. The key agenda of the conference was to promote reproductive health and well-being, planned and safe sexual and reproductive alternatives for individuals as well as couples that emphasize on their right to decide upon the age of marriage, size of family, and probable gap between consecutive childbirth. Sexuality and reproduction are the main facets of an individual’s identity and they are also basic to human welfare fulfilling the relationships within diverse cultural contexts.

The idea of reproductive health and management has an elementary vision that each child who is born is wanted; every birth which is facilitated is safe, every individual be it young or old is free from sexually transmitted infections, and furthermore, every woman is cared with dignity. It is evident that access to better quality health care facilities and services will provide significant help to women so that they can experience safe pregnancy and protected childbirth all over the world. However, women residing in developing countries still face disparities regarding the attention and health care services provided to them pre and post pregnancy and during pregnancy. They suffer from problems such as unwanted pregnancies, the incidence rate of maternal death and disorders is also evidently high, and they are vulnerable to sexually transmitted infections including HIV. Gender based violence; female genital mutilation and other conditions associated with female reproductive system and sexual behaviour are also a great concern in developing and underdeveloped countries (UNFPA, 2015).

Historical development of the concept of Reproductive health

During the 1960s, UNFPA established with a mandate to raise awareness about population “problems” and to assist developing countries in addressing them. At that time, the talk was of “standing room only”, “population booms, demographic entrapment” and scarcity of food, water and renewable resources. Concern about population growth (particularly in the developing world and among the poor) coincided with the rapid increase in availability of technologies for reducing fertility – the contraceptive pill became available during the 1960s along with the IUD and long acting hormonal methods.

In 1972, WHO established the Special Program of Research, Development and Research Training in Human Reproduction (HRP), whose mandate was focused on research into the development of new and improved methods of fertility regulation and issues of safety and efficacy of existing methods. Modern contraceptive methods were seen as reliable, independent of people’s ability to practice restraint, and more effective than withdrawal, condoms or periodic abstinence. Moreover, they held the promise of being able to prevent recourse to abortion (generally practiced in dangerous conditions) or infanticide. Population policies became widespread in developing countries during the 1970s and 1980s and were supported by UN agencies and a variety of NGOs of which international planned parenthood federation (IPPF) is perhaps the most well known. The dominant paradigm argued that rapid population growth would not only hinder development, but was itself the cause of poverty and underdevelopment. Almost without exception, population policies focused on the need to restrain population growth; very little was said about other aspects of population, such as changes in population structure or in patterns of migration. Given their genesis among the social and economic elites, it is perhaps hardly surprising that the family planning programs that resulted were based on top-down hierarchical models and that their success was judged in terms of numeric goals and targets – numbers of family planning acceptors, couple-years of protection, numbers of tubal ligations performed. Donors, anxious to demonstrate that their aid money was being well-spent, encouraged such performance evaluation indicators. In the drive for efficiency and effectiveness, they supported the establishment of free-standing “vertical” family planning bodies, generally quite separate from other related government sectors such as health, often, indeed, set up within the office of the president or the prime minister as a mark of their importance.

The 1994 ICPD has been marked as the key event in the history of reproductive health. It followed some important occurrences that made the world to think of other ways of approach to reproductive health.

What was the impetus behind the paradigm shift that Cairo represents and that has been reinforced in the recent special session of the UN General Assembly? Three elements are of particular importance.

• The first was the growing strength of the women’s movement and their criticism of the over-emphasis on the control of female fertility – and by extension, their sexuality – to the exclusion of their other needs.
• A second key development was the advent of the HIV/AIDS pandemic; suddenly it became imperative to respond to the consequences of sexual activity other than pregnancy, in particular sexually transmitted diseases. But perhaps more important, it became possible (and essential) to talk about sex, about sexual relations outside of marriage as well as within it, and about the sexuality of young people.
• A third development, that brought a unity to the others, was the articulation of the concept of reproductive rights. An interpretation of international human rights treaties in terms of women’s health in general and reproductive health in particular gradually gained acceptance during the 1990s.

    Three rights in particular were identified:

• The right of couples and individuals to decide freely and responsibly the number and spacing of children and to have the information and means to do so;
• The right to attain the highest standard of sexual and reproductive health; and,
• The right to make decisions free of discrimination, coercion or violence.

   Subsequent articulations of reproductive rights have gone further, so that, for example, maternal death is defined as a “social injustice” as well as a “health disadvantage” thus, placing an obligation on governments to address the causes of poor maternal health through their political, health and legal systems.

These strands became fused in the concept of reproductive health, which was first clearly articulated in the preparations for Cairo and which has become a central part of the language on population. The new paradigm reflects a conceptual linking of the discourse on human rights and that on health. It proposes a radical shift away from technology-based, directive, top-down approaches to programme planning and implementation. It argues that it is possible to achieve the stabilization of world population growth, while attending to people’s health needs and respecting their rights in reproduction. It reinforces and gives legitimacy to the language of health and rights, and validates concerns raised by the international women’s movement and by health professionals who had recognized the needs of people in sexuality and reproduction beyond fertility regulation.

Issues regarding reproductive health

In April 1997, the World Health Organization, the United Nations Children’s Fund, and the United Nations Population Fund issued a joint statement that summarized the importance as well as the challenges inherent to addressing harmful health practices: “Human behaviours and cultural values have meaning and fulfil a function for those who practice them. People will change their behaviour when they understand the hazards and indignity of harmful practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture.” Health professionals worldwide struggle with how to address harmful health practices. The basic question of whether a practice is harmful or necessary is often hotly debated—debates that sometimes rely on simplistic divisions between “Western” and local medical values.

In many cases, this division masks more complicated reasons for defending harmful practices, the victims of which tend to be women and children and others who are less powerful in their society. These reasons often include power struggles, local and national politics, and/or lack of understanding about the risks of the practice. Sometimes a harmful practice is so deeply rooted that it seems impossible to change. But in every country people have pushed forward positive social changes, and harmful practices have been ended. For example, foot binding was once the norm in many parts of China. Women without tiny, hobbled feet were considered unmarriageable. Women were completely dependent on men since they were unable to walk well.

Yet, the practice was eliminated in a short time, in conjunction with major political, social, and economic changes in that society. In the nineteenth-century Europe, women endured pain and physical damage from constrictive whalebone corsets which caused their waists to appear slim. This practice was also recognized as dangerous, and fell out of favour. At the same time, Western medicine is recognizing the benefits of some traditional health practices, which fall into an overarching category described by some as “Indigenous Knowledge.” Traditional plants are being researched by drug companies, and the health benefits of non-Western therapies such as Indian yoga, Chinese acupuncture, and African community support systems are increasingly being recognized. As leaders in Western medicine learn more about helpful traditional practices, and vice versa, health professionals in all countries can draw from the best of these worlds in order to help their clients make healthy choices.

Harmful Practices being practiced:

• Female genital mutilation: primarily in Africa.
• Early marriage: Asia, the Middle East, Africa.
• Severely restricted weight gain during pregnancy: Philippines, France.
• Withholding colostrum (initial breast milk with special nutritional value) from newborn: China, Guinea Bissau.
• Low levels of breast feeding: United States, France, other European countries.
• Postpartum nutritional restrictions: Latin America
• Vaginal douching: United States, selected European countries.
• “Dry sex” practices (removal of vaginal fluid with absorbent materials): Africa, Latin America, and South-east Asia.
• Breast and penis implants: United States, Europe, Southeast Asia, other countries.

    Adolescent Reproductive Health

World Health Organization defines adolescents as individuals between 10 and 19 years of age. The broader terms “youth” and “young” encompass the 15 to 24 year-old and 10 to 24 year-old age groups, respectively.

For girls, puberty is a process generally marked by the production of estrogen, the growth of breasts, the appearance of pubic hair, the growth of external genitals, and the start of menstruation. For boys, it is marked by the production of testosterone, the enlargement of testes and penis, a deepening of the voice and a growth spurt.

The pubertal period is characterized by:

• Initial appearance of secondary sex characteristics to sexual maturity.
• Transition from the state of total socio-economic dependence to relative independence.
• Period of rapid physiological changes and vulnerability to physical, psychological and environmental influences.
• Period of physical, biological, psychological and social maturity from childhood to adulthood. Transition from childhood to adulthood involves adjustment encompassing physiological, psychological, cognitive, social and economic changes. The process is universal, but varies by individual and culture.

     Adolescent reproductive health is affected by pregnancy, abortion, STIs, sexual violence, and by the systems that limit access to information and clinical services. Reproductive health is also affected by nutrition, psychological well-being, and economic and Reproductive Health gender inequities that can make it difficult to avoid forced, coerced, or commercial sex.

In many parts of the world, women marry and begin childbearing during their adolescent years. Pregnancy and childbirth carry greater risk of morbidity and mortality for adolescents than for women in their 20s, especially where medical care is scarce. Girls younger than age 18 face two to five times the risk of maternal mortality as women aged 18-25 due to prolonged and obstructed labour, haemorrhage, and other factors.

Potentially life- threatening pregnancy-related illnesses such as hypertension and anaemia also are more common among adolescent mothers, especially where malnutrition is endemic. One in every 10 births worldwide and 1 in 6 births in developing countries is to women aged 15-19 years.

About one in 10 abortions worldwide occurs among women age 15-19 and each year one million to 4.4 million adolescents in developing countries undergo abortion, and most of these procedures are performed under unsafe conditions due to:

• Lack of access to safe services.
• Self-induced methods
• Unskilled or non-medical providers
• Delay in seeking procedure

    Adolescent unwanted pregnancies often end in abortion. Surveys in developing countries show that up to 60 percent of pregnancies to women below age 20 are mistimed or unwanted. In Canada, Great Britain, New Zealand, and the United States in the late 1980s, more than 50 percent of all abortions occurred in women under 25. Pregnant students in many developing countries often seek abortions to avoid being expelled from school.

Induced abortion often represents a greater risk for adolescents than for older women. Adolescents tend to wait longer to get help since they cannot access a provider or because they may not realize that they are pregnant; this risk is compounded in conditions.

Some of the complications of abortion are infection, haemorrhage, and intestinal perforation, injury to reproductive organs and toxic reactions to drugs. These complications can result in infertility, psychological trauma or death.

The perspectives of young people around the world are moulded by the situations in which they live. Girls with little, if any, education may view early marriage and childbearing as their only path in life. Children living in poverty may feel no reason to plan for the future and protect their health. Other factors that influence adolescent health and behaviour include:

• Gender inequities and sexual exploitation
• Cultural expectations about childbearing.

    Violence against Women

Globally, at least one in three women has experienced some form of gender-based abuse during her lifetime. Violence against women is any act of gender-based violence that results in, or is likely to result in, physical, sexual, psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life. Abuse of women and girls is best understood within gender framework because it stems in part from women’s and girls’ subordinate status in the society. In addition to causing injury, violence increases women’s long-term risk of a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse, and depression. Women with a history of physical or sexual abuse are also at increased risk for unintended pregnancy, sexually transmitted infections, and adverse pregnancy outcomes. Females of all ages are victims of violence, in part because of their limited social and economic power compared with men.

Violence against women (VAW) encompasses, but is not limited to:

• Spousal battering
• Sexual abuse of female children
• Dowry-related violence
• Rape including marital rape
• Traditional practices harmful to women such as Female Genital Mutilation (FGM).

Non-spousal violence

• Sexual harassment and intimidation at work and in school
• Trafficking in women
• Forced prostitution
• Violence perpetrated or condoned by the state, such as rape in war

    In the 1990s, Violence against women, VAW emerged as a focus of international attention and concern. In 1993, the UN General Assembly passed the Declaration on the Elimination of Violence against Women. The Cairo Program of Action recognized gender-based violence as an obstacle to women’s reproductive and sexual health and rights. The Beijing Declaration and Platform for Action devoted an entire section to the issue of violence against women. In 1996, the 49th World Health Assembly adopted a resolution declaring violence a public health priority. In 1999, the United Nations Population Fund declared VAW a public health priority.

Women who live with violent partners have a difficult time protecting themselves from unwanted pregnancy or disease. Violence can lead directly to unwanted pregnancy or STIs, including HIV infection, through coerced sex, or else indirectly by interfering with a woman’s ability to use contraceptives, including condoms.

One in every four women is physically or sexually abused during pregnancy, usually by a partner. Violence during pregnancy has been associated with miscarriage, late entry into prenatal care, stillbirth, premature labor and birth, fetal injury, and low birth weight.

Health care providers can play a crucial role in addressing violence against women because health care providers often are well placed to recognize victims of violence and to help them. Since violence increases the risk of other health problems for women, early help can prevent serious conditions that follow from abuse. They can help solve the problem of violence against women if they learn how to ask clients about violence, if they become better aware of signs that can identify victims of domestic violence, and help women protect themselves by developing a personal safety plan.

Health workers can educate themselves about physical, sexual, and emotional abuse, and explore their own biases, fears and prejudices. They can also provide supportive, non-judgmental care to victims of violence and ask clients about in a friendly, gentle way.

Female genital mutilation (FGM)

It is estimated that at least 2 million girls are at risk of female genital mutilation (FGM) each year. FGM is practiced in at least 26 of 53 African countries. Prevalence varies from 98 percent in Somalia and 97 percent in Egypt to 5 percent in Uganda. The practice is also found among some ethnic groups in Oman, the United Arab Emirates, and Yemen, as well as parts of India, Indonesia, and Malaysia. FGM has become a health and human rights issue in Australia, Canada, England, France, and the United States, due to the continuation of the practice by immigrants from countries where FGM is common.

FGM comprises all procedures involving partial or total removal of the external female genitalia or other injuries to the female genital organs for cultural or non-therapeutic reasons. In 1995, the World Health Organization developed the four broad categories for FGM.

Health consequences of FGM seem to vary according to the type and severity of the procedure. Complications may range from immediate, such as bleeding and shock, to a wide range of longer-term problems for women and their newborn children. Psychological effects may be profound and permanent. Additionally, FGM may increase the risk of HIV or Hepatitis B, due to unclean conditions often associated with the procedure.

Early Marriage (EM)

It has been a common practice, particularly in much of rural Ethiopia and India to get girls married at an early age as 10 –15 years old. The young adolescent or preadolescent girl is not ready physically and psychologically for intercourse, pregnancy, child bearing and child rearing. Some of the reasons for early marriage are:

• Parents desire to see the marriage of their daughters and their grandchild before they die
• Strengthen the family or business ties between the two parties to be married
• Avoid the possibility of a daughter not getting married or becoming not eligible for marriage
• Avoid premarital sex or loss of virginity and its consequences

    Harmful effects of early marriage include:

• Psychological effects on the girl bride which lead to different somatic problems. The small genitalia are traumatized ending up in tears, bruising, cystitis, and damage to the urethra.
• Preclampsia, prolonged and obstructed labour leading to fistula formation, haemorrhage and shock at delivery.
• Still born babies.
• Loveless marriage often ending in divorce.
• Difficulty in managing a household by the young girl.
• Deprivation of the girl of her education leading to poor opportunity for employment and gainful income

    Magnitude of Reproductive Health Problem

The term “Reproductive Health “is most often equated with one aspect of women’s lives; motherhood. Complications associated with various maternal issues are indeed major contributors to poor reproductive health among millions of women worldwide.

Half of the world’s 2.6 billion women are now 15 – 49 years of age. Without proper health care services, this group is highly vulnerable to problems related to sexual intercourse, pregnancy, contraceptive side effects, etc.

Death and illnesses from reproductive causes are the highest among poor women everywhere. In societies where women are disproportionately poor, illiterate, and politically powerless, high rates of reproductive illnesses and deaths are the norm.

Women in developing countries and economically disadvantaged women in the cities of some industrial nations suffer the highest rates of complications from pregnancy, sexually transmitted diseases, and reproductive cancers. Lack of access to comprehensive reproductive care is the main reason that so many women suffer and die. Most illnesses and deaths from reproductive causes could be prevented or treated with strategies and technologies well within reach of even the poorest countries. Men also suffer from reproductive health problems, most notably from STIs. But the number and scope of risks is far greater for women for a number of reasons.

Reproductive Health in Developing Countries

While there is growing programmatic and research interest in addressing the sexual and reproductive health situation and needs of adolescents in India, the thrust is implicitly on the unmarried, rather than on the married as well. Yet the evidence is that sexual activity among adolescent females in India takes place overwhelmingly within the context of marriage. For example, as many as 34 per cent of adolescent girls aged 15-19 are already married and presumably sexually active, while fewer than 10 per cent of unmarried girls are reported to be sexually experienced. Not only are larger proportions of adolescents sexually active within a marital context, but also, as is well known, married adolescents are far more likely to experience regular sexual relations than are unmarried sexually active adolescents.

The relative lack of focus on this large segment of married adolescent girls has been justified on the grounds that their needs are legitimately met in services available to adult women. Yet it is very likely that the sexual and reproductive health situation, the ability to exercise informed choice and hence the needs of married adolescent girls are quite different from those of married adult women (or unmarried adolescent girls), and that the unique needs of this large group of sexually active women remain un-served. Despite laws (Child Marriage Restraint Act of 1978) advocating 18 as the legal minimum age at marriage for females in India, large proportions of females continue to marry well before that age. Researchers point out the social and political forces that often work through women by constraining their options. Paternalistic control of women’s sexual and reproductive behaviour manifests itself in laws and policies. For example, access to voluntary sterilization services in some developing countries is contingent on the number of caesarean sections a woman has undergone. Marriage and family laws often prescribe a younger age of marriage for women than for men and restrict women to childbearing and service roles, while denying them equal opportunities available to men (Wang and Pillai, 2001). Reproductive and sexual ill-health accounts for 20% of the global burden of ill-health for women and 14% for men. World Health Organization adopted the first global strategy on reproductive health in 57th World Health Assembly (WHA) in May 2004. Five priority aspects of reproductive and sexual health are targeted:

• Improving antenatal, delivery, postpartum and new born care.
• Providing high-quality services for family planning, including infertility services.
• Eliminating unsafe abortion.
• Combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities.
• Promoting sexual health.

   The strategy was developed as a result of extensive consultations in all regions with representatives from ministries of health, professional associations, non-governmental organizations, United Nations partners and other key stakeholders. It lays out actions needed for accelerating progress towards the attainment of the Millennium Development Goals (MDGs) and other international goals and targets relating to reproductive health, especially those from the International Conference on Population and Development in 1994 and its five-year follow-up (Reproductive Health Matters, 2005). The Millennium Development Goals, which grew out of the United Nations Millennium Declaration was adopted by 189 Member States in 2000, provided the new international framework for measuring progress towards sustaining development and eliminating poverty. Of the eight Goals, three improve maternal health, reduce child mortality and combat HIV/AIDS, malaria and other diseases are directly related to reproductive and sexual health, while four others eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, and ensure environmental sustainability have a close relationship with health, including reproductive health (Reproductive Health Matters, 2005). For the last five decades, family planning programs formed the foundation of global policies of population control. One of the most significant changes in the current view on population as a factor in development took place at the 1994 International Conference on Population and Development (ICPD). The conference pointed out the need for the global monitoring of women’s reproductive health and reproductive rights status and redefined the discourse of reproduction as a process of empowering women and eliminating social inequalities and constraints for women. The new thinking strongly adheres to the view that population growth can be controlled by women’s advancement socially, politically and economically. This view was endorsed by some 180 national delegations at the conference regardless of their differences in cultural and religious identities (World Bank, 1998). While a women’s health movement has been identifiable since the 1970s, with a growing internationalism, it is only in the last five years that the transition from programmes in which women’s health needs were primarily addressed through family planning (FP) and maternal and child health programmes (MCH), to reproductive health care programmes, has begun to take place within official and NGO development assistance. Within the changing policy framework, there are also encouraging indications that NGOs who have traditionally been unwilling to engage in family planning programmes are switching their analysis, in recognition that high fertility may be a problem for individual women, and that freedom to choose how many children you have is an important human right. ‘Childbirth by choice’ is being seen in the context of wider reproductive health needs. Current definition of reproductive rights was formulated at the 1994 International Conference on Population and Development known as the Cairo Conference. Women’s reproductive rights were defined as the right to decide freely and responsibly the number and spacing of their children, to be educated and informed in this respect, to have access to reproductive health services, and to have control over their bodies and attain the highest reproductive health standards (Pillai and Wang, 1999). Studies also suggest that the presence of reproductive rights is essential for launching public health initiatives to improve reproductive health. The Cairo conference (1994) and the Beijing conference (1995), furthermore, reinforced the need to enhance the link between reproductive health and reproductive rights as a global strategy to improve reproductive health. The World Health Organization convened two interagency meetings in 1996 and 1997 on reproductive health and reproductive rights indicators for global monitoring. The meetings brought together representatives of multilateral and bilateral agencies, nongovernmental organizations, and women’s groups, and recognized the need for selecting indicators of reproductive health and reproductive rights (Wang and Pillai, 2001). In 1951, India became the world’s first nation to launch a family planning programme. Decades later, when the International Conference on Population and Development (Cairo, 1994) prompted a paradigm shift in population programmes, with the advocacy of client centred and quality-oriented reproductive health approaches, India formulated appropriate policy and programmatic responses such as National population policy, national rural health mission, reproductive and child health programme, etc.

The National Population Policy (India) was formulated in the year 2000. It affirms the government’s commitment to promote voluntary and informed choice, and continuation of the target-free approach in family planning service delivery.

The National Rural Health Mission (NRHM) was launched in 2005. It objective was to revamp the public healthcare delivery system and seeks to provide accessible, affordable and quality healthcare to rural population.

A national level Reproductive and Child Health Programme II (RCH II) was introduced in 2005 and focuses on addressing reproductive health needs of the population through evidence-based technical intervention through wide range of service delivery network. There is implicit emphasis on addressing the equity dimension in coverage, while maintaining focus on quality.

Conditional Cash Transfer schemes like Janani Suraksha Yojana (for promoting institutional deliveries) were introduced to help address economic barriers for access to services. Promotion of maternal and child health has been one of the most important objectives of the Family Welfare Programme in India.

The Government of India took steps to strengthen maternal and child health services as early as the First and Second Five-Year Plans (1951-56 and 1956-61).

As part of the Minimum Needs Programme initiated during the Fifth Five-Year Plan (1974-79), maternal health, child health, and nutrition services were integrated with family planning services. The primary aim at that time was to provide at least a minimum level of public health services to pregnant women, lactating mothers, and pre-school children.

In 1992-93, the Child Survival and Safe Motherhood Programme continued the process of integration by bringing together several key child survival interventions with safe motherhood and family planning activities (Ministry of Health and Family Welfare, 1992).

In 1996, safe motherhood and child health services were incorporated into the Reproductive and Child Health Programme. This new programme seeks to integrate maternal health, child health, and fertility regulation interventions with reproductive health programmes for both women and men. In rural areas, the government delivers reproductive and other health services through its network of Primary Health Centres (PHCs), sub-centres, and other government health facilities. In addition, pregnant women and children can obtain services from private maternity homes, hospitals, private practitioners, and in some cases, nongovernmental organizations (NGOs). In urban areas, reproductive health services are available mainly through government or municipal hospitals, urban health posts, hospitals and nursing homes operated by NGOs, and private nursing and maternity homes.

The paradigm policy shift in India from promoting fertility reduction only to meeting women’s reproductive and sexual health needs a more useful concept for measuring ‘unmet need’ for services in programme planning, one such as the HARI index, that captures the extent to which individual women are achieving their reproductive intentions in good health.

In 1994, Jain and Bruce’s modified ‘Helping Individuals Achieve their Reproductive Intentions’ (HARI) index was proposed for assessing the performance of family planning and reproductive health programmes, based on whether individuals could achieve their reproductive intentions in a healthy manner.

The index is calculated by the proportion of women failing to achieve any of the following during a specified time interval:

• A desired pregnancy with a positive outcome
• The prevention of an unplanned pregnancy
• Terminating an unwanted pregnancy safely
• Achieving the desired interval between two consecutive births
• Preventing any associated reproductive morbidity.

    In India, it was unmet need for family planning as measured in the National Family Health Surveys I (1992-93) and II (1998-99) that guided the formulation of the Reproductive and Child Health (RCH) Programme (1997), and the National Population Policy of 2000, respectively. In many developing countries, women bear a very high proportion of the physical, economic, and psychological costs of childbearing and childrearing. Protracted child-bearing with inadequate spacing between pregnancies is likely to induce both physical and psychological harm. There is a need to raise awareness among girls, parents, teachers, and community leaders through school and community based programmes about the negative impact of early marriage and pregnancy on women and children’s health.

Interventions for safe reproductive health and child care

The components of reproductive health care, including the relevant components of the ICPD programme of action as endorsed by WHO and other agencies of the United Nations are:

• Safe motherhood: prenatal care, safe delivery, essential obstetric care (EOC), perinatal and neonatal care, postnatal care and breastfeeding
• Family planning information and services
• Prevention and management of infertility and sexual dysfunction in both men and women
• Prevention and management of complications of abortion
• Provision of safe abortion services, where the law permits
• Prevention and management of reproductive tract infections, especially sexually transmitted infections (STIs), including HIV infections and Acquired Immunodeficiency Syndrome (AIDS)
• Promotion of healthy sexual maturation as from pre-adolescence, responsible and safe sex throughout the lifetime and gender equality
• Elimination of harmful practices, such as female genital mutilation, premature marriage, and domestic and sexual violence against women
• Management of non infectious conditions of the reproductive system such as genital fistula, cervical cancer, complications of female genital mutilation and reproductive health problems associated with menopause.

    The African and South Asian regions endorse the WHO global priorities on reproductive health, especially family planning information and services, prevention and management of complications of abortions, prevention of maternal and newborn deaths and disabilities- safe motherhood, prevention and management of STIs. Other priorities include building gender considerations into all programmes, reduction of FGM, and promotion of reproductive health for young people. In all priorities, special attention is placed on under-served groups like men, refugees, and displaced people, the disabled, indigenous populations, etc.

These reproductive health strategies are the outcome of consultations at various levels with experts from governmental organization and United Nations agencies, within and outside Africa. It is a tool to assist Member States and partners to identify priorities and plan their programmes and interventions at various levels.

Summary

To conclude, it can be clearly justified by the text above that reproductive health is concerned with reproductive system, its function and the processes for every stage of life. The International Conference of Population Development health at Cairo in 1994, was a key event in the history of reproductive health. This conference raised concerns n the health of women and their reproductive rights. Consequently, right to proper sex education, for access to proper sexual and reproductive health measures were given to the women and couples around the world. Apart from the rights and there are some harmful practices which have been practiced around the world which pose to be a threat to the reproductive health of individuals. Practices such as female genital mutilation, marriage at an early age, abstinence to breast feed, withholding colostrums, violence against women, etc. are present in countries like Africa, Middle East Africa, a few European countries, and South-East Asia. Overall, the reproductive and sexual ill-health accounts for 20% of the global burden of ill health among women. Owing to such increase in rates, the World Health Organization has adopted a global strategy on reproductive health in May 2004 which targets upon five priorities in the aspects of reproductive and sexual health.

References:

• Mosse, J. C. (1994). From family planning and maternal and child health to reproductive health. Gender & Development, 2(2), 6–12.
• Santhya, K. G., & Jejeebhoy, S. J. (2003). Sexual and Reproductive Health Needs of Married Adolescent Girls. Economic & Political Weekly, 38(41), 4370–4377.
• Strategy to Accelerate Progress towards the Attainment of International Development Goals and Targets Related to Reproductive Health. (2005). Reproductive Health Matters, 13(25), 11– 18.
• Wang, G.-Z., & Pillai, V. K. (2001). Measurement of Women’s Reproductive Health and Reproductive Rights: An Analysis of Developing Countries. Springer, 54(1), 17–35
• Wang, G.-Z., & Pillai, V. K. (2001). Women’s Reproductive Health: A Gender-Sensitive Human Rights Approach. Acta Sociologica, 44(3), 231–242.
• www.unfpa.org/sexual-reproductive-health, accessed on April 21, 2017.
• www.wikipedia.org/wiki/Reproductive_health, accessed on April 20, 2017.

    Suggested readings:

• Wingood, G. M., & DiClemente, R. J. (Eds.). (2013). Handbook of women’s sexual and reproductive health. Springer Science & Business Media.
• Speizer, I. S., & Kulczycki, A. (2014). Critical Issues in Reproductive Health. New York: Springer publications.
• Pathak, R. K. (2008). Bio-social Issues in Health. A. K. Sinha (Ed.). Northern Book Centre.