15 Reproductive survey

Dr. SAA Latheef

Contents

1. Definition and scope of reproductive health

2. Reproductive health indicators

2.1. Total Fertility Rate

2.2. Contraceptive Prevalence

2.3. Maternal mortality ratio

2.4. Antenatal care coverage

2.5 Births attended by skilled health personnel

2.6 Availability of comprehensive essential obstetric care availability of comprehensive essential obstetric care

2.8 Perinatal mortality rate

2.9. Prevalence of low birth weight

2.10. Prevalence of positive syphilis serology in pregnant women

2.11. Prevalence of anaemia in women

2.12. Percentage of obstetric and gynecological admissions owing to abortion

2.13. Reported prevalence of women with genital mutilation

2.14. Prevalence of infertility in women

2.15. Reported incidence of urethritis in men

2.16. Prevalence of HIV infection in pregnant women

2.17. Knowledge of HIV-related preventive practices

3. Obstetric history of women

3.1. Identification data

3.2. Chief complaints

3.3. History of presenting illness

3.4. History of present pregnancy

3.5. Past Obstetric history

3.6. Gynecology history

3.7. Contraceptive history

3.8. Medical history

3.9. Surgical history

3.10. Social history

3.11. Drug and allergy history

3.12. Family history

3.13. Systemic review

Summary

Learning Objectives:

•  To discuss the definition and scope of reproductive health;
•  To understand the indicators of reproductive health; and
•  To study the obstetrics history taking.

1. Definition and scope 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 relating to the reproductive system and to its functions and processes (UNO, 1994). This concept assumes that people have the ability of satisfying and safe sex and, they have the capability for reproduction and choice to decide. The scope of reproductive health covers from the conception to old age and emphasize maintaining good health and prevention and treatment of illness (WHO, 2006).

Reproductive health care involves information, education, communication; services to adolescents; discouraging practices like genital mutilation; prevention and management of gender violence; prevention and treatment of sexually transmitted diseases; treatment of obstetric complications and safe termination of unwanted pregnancies; promoting safe motherhood; and education and provision of clinical services for family planning (WHO, 2006). Economic status, gender, education and social status were found to be the predictors in the use and gaining access to reproductive health care in India (Sanneving, 2013).

2. Reproductive health indicators:

In the year 2000, United Nation Organization organized a millennium summit. In this summit, all member countries had resolved to achieve sustainable development and eradicate poverty. In this event, eight goals were set known as Millennium Development Goals. The fifth goal advocated for reducing maternal mortality and achieving universal access to reproductive health care. International agencies consented for 17 indicators to monitor the reproductive health goals. These indicators comprise indicators of outcome, access and use of health care system. These indicators are described in the following section of this module.

2.1. Total Fertility Rate (TFR):

Total fertility is the number of births a woman would have by the end of her reproductive life if she experienced the currently prevailing age-specific fertility rates from age 15-49.TFR is expressed per 1000 women. Age specific fertility rate (ASFR) refers to the number of women in each age group and

the number of births to women in that age group (WHO,2006). Age specific fertility rate (ASFR)= 

Either for one year or five years ASFR is calculated. When AFSR is calculated for five years, it is multiplied by 5. ASFR can also be also be calculated for seven ASFRs each ranging 5 year age group namely 15–19, 20–24, 25–29, 30–34, 35– 39, 40–44 and 45–49 years. The age group 15-49 years for women is referred as reproductive age. Summation of ASFR (multiplied by 5) and division by 1000 give the total fertility rate (TFR). It is expressed per woman.

In surveys results, the data is disaggregated by 15-44 and by 15-49 age groups respectively. TFR is the number of births a woman would have if she lived from age 15 – 50 years and experienced throughout her reproductive life exactly the ASFRs observed for the year in question.TFR is also known as total period fertility rate (TPFR), as is based on the ASFRs prevalent at a particular time. The births preceding three years is generally taken for calculating ASFR and TFR to avoid displacement of births and underreporting by the old women is recommended. The data for ASFR and TFR, are collected from vital registrations, population census and population surveys. Data on birth counts can be collected from vital registrations and information on women of reproductive age from census. Survey results provide data on fertility and trends. Survey data suffer from response bias and age misclassification. To prevent age misclassification and sampling errors in the calculation of TFR, births preceding 36 months is considered. Presentation of sampling errors and confidence interval along with TFR is advocated. As ASFR shown to be sensitive to changes in fertility, collecting of ASFR data by age, socio-economic status and residence is advised.TFR is a good indicator of population momentum and poor physical reproductive health. It is independent of age structure. It also been used as surrogate marker to assess the family planning services. The limitations of TFR include is its hypothetical approach (WHO, 2006).

2.2. Contraceptive Prevalence:

Contraceptive prevalence is the percentage of women of reproductive age who are using (or whose partner is using) a contraceptive at a given point in time. In India, 98% of women and 99% of men in the age group of 15-49 reported awareness on one or more methods of contraception as per Family welfare statistics, Government of India, 2011.

Contraceptive Prevalence= Number of women of reproductive age at risk of pregnancy who are using (or whose partner is using) a contraceptive method at a given point in time/ Number of women of reproductive age at risk of pregnancy at the same point in time

Here, reproductive age refers to all women aged 15-49 years. At risk of pregnancy implies women who are sexually active, not infecund, not pregnant and not amenorrhoeic. Contraceptive methods are two types clinical and supply (modern) and non-supply (traditional) methods. Clinical and supply(modern) methods consists of female and male sterilization, intrauterine devices (IUDs), hormonal methods (oral pills, injectables, and hormone-releasing implants, skin patches and vaginal rings), condoms and vaginal barrier methods (diaphragm, cervical cap and spermicidal foams, jellies, creams and sponges).Traditional methods comprise rhythm, withdrawal, abstinence and lactation amenorrhoea.

Data on prevalence of contraceptive use is collected using population based surveys, small scale or focused surveys. Family planning programme records can be helpful in reporting trends and details of usage. The drawback of this type of information includes double counting of users, poor quality of data and data manipulation. Interview methods are used to collect the data on contraceptive prevalence involving married and couple on consensual unions where culture permits. Documentation of age wise usage of contraceptives may be useful to know the information on type of contraceptives used by different age groups. Prevalence data depend on the response of the user and reveal information on prevalent contraceptive methods, contraceptive services coverage and preferred methods. This measure may not useful to know the prevalence of more than on type of contraceptive method practiced by the users (WHO,2006).

2.3. Maternal mortality ratio:

Maternal mortality ratio is the number of maternal deaths per 100,000 live births.

Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but other than from accidental or incidental causes(ICD-10,1992). Direct obstetric death refers to maternal death resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions or incorrect treatment, or from a chain of events resulting from any of the above (ICD-10,1992). Maternal death resulting from previously existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes, but that was aggravated by physiological effects of pregnancy is known as indirect obstetric death(ICD-10,1992). Late maternal death is defined as the death of a woman from direct or indirect causes more than 42 days but less than one year after termination of pregnancy (ICD-10, 1992).

Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of cause of death is known as Pregnancy-related death (ICD-10, 1992). Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born (ICD-10, 1992).

Vital registrations, health facility-based data and population-based surveys or surveillance are the sources of the data for maternal mortality ratio. The maternal mortality is underreported in vital registrations due to sudden death, failure of relatives to incur time or travel cost to register death, feeling of blame or culpability among relatives to report death and misclassification of deaths. Data from health facility may not be qualitative because of selective nature, inaccuracy of registers and case sheets, omission of data and inaccessibility.

Cross-sectional household surveys, continuous population surveillance data, hospital and health-centre records and key informants are another source of information but they require larger sample size, time and cost intensive. Sisterhood method involves asking questions to sisters about the survival of their sisters and women at risk for each household. Two methods are used in this type of surveys i.e indirect and direct (Graham et al., 1989; Stanton et al., 2000). In indirect method, fewer questions are asked and estimates are reported for 10-12 years preceding the survey. This type of method may not be suitable to area, where low fertility is the norm and population is dynamic. In direct method, estimates are provided for 3-4 years prior to the survey and involve large sample and complex questions, this method time and cost intensive. This method may not be suitable to monitor trends. Both methods provide only estimates not actual figures.

Confidential surveys provide information on number of maternal deaths, causes, avoidable factors and guidelines for improving the clinical outcomes. This type of surveys works better where good infrastructure is available to collect information. In view of cost intensive nature, the data is collected every 5-10 years. Disaggregation of data into urban-rural is not appropriate unless there is a sufficient evidence on the quality of the data. The interpretation of the data should be done taking variation into consideration in the estimations.

Maternal mortality ratio is a useful indicator to assess the magnitude of maternal deaths; number of pregnant women at risk; health status; the status of women in the society and; the functioning of the health system. In India, the reported maternal mortality ratio for the year 2013 was 190 per 100000 live births (World bank, 2013). Reporting of confidence interval with maternal mortality ratio can avoid non-sampling errors. The possible confounding variables influencing the maternal mortality ratio are geography, general health status, levels of anemia or malaria, and socioeconomic factors. The ICD-10 demands specification of numerator from three categories such as direct and indirect maternal deaths up to 42 days postpartum, late maternal deaths and pregnancy-related deaths. The limitation of this indicator is that it cannot reveal the reasons and ways to reduce the maternal mortality ratio. In many developing countries, the figures suggested by this measure indicate broad level but not actual statistics (WHO, 2006).

2.4. Antenatal care coverage (ANC):

The proportion of pregnant women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to pregnancy.

Antenatal care coverage = Number of pregnant women attended, at least once during their pregnancy, by

Skilled health attendant (Skilled attendant) refers to an accredited health professional( midwife, doctor or nurse),who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns(WHO,2004). Live birth may be defined as the birth of a fetus after 22 weeks’ gestation or weighing 500 g or more that shows signs of life—breathing, cord pulsation or with audible heart beat (ICD-10, 1992).

The sources for data collection for this indicator are health service data and household surveys. Health services data are useful when utilization is high. The disadvantages of health service data is double counting, incomplete or missing record and poor quality data (Graham et al., 1996; WHO, 1997). Household surveys provide data on maternity care, live births and age and socio-economic status. Confidence interval can be calculated for the indicator but cost intensive. Data can be collected in terms of urban and rural areas, to monitor the progress of ANC. This indicator is useful to measure coverage of antenatal and emergency obstetric services and monitoring newborn health/survival programmes (McDonagh,1996; Vanneste et al.,2000). In India, antenatal cover for single visit for the period 2008-2012 was 74% (Unicef, 2013). In combination with other indicator “skilled attendant at delivery”, this indicator can be used. It can also serves as surrogate measure to assess the progress of programmes to reduce the maternal mortality. Usage of this indicator with other indicators is helpful in better assessment of the situation and the study at different levels, may provide information on disparities in services, number and times of ANC utilization and the proportion of users(WHO, 2006).

2.5. Births attended by skilled health personnel:

The proportion of births attended by skilled health personnel.

Skilled health attendant (Skilled attendant) is an accredited health professional(midwife, doctor or nurse),who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns (WHO,2004). Live birth is defined as the birth of a fetus after 22 weeks’ gestation or weighing 500 g or more that shows signs of life— breathing, cord pulsation or with audible heart beat (ICD-10,1992).

The data sources of this indicator include health service data and household surveys. Health service data is routine source, involves public sector only and its utilization is low and introduce selection bias in the data. Household surveys are important source of information and reports counts, confidence interval, trends and differentials. This indicator is disaggregated by place of delivery, type of skilled health personnel, urban/rural and socioeconomic status. This indicator measures health system’s functioning and possibility of adequate coverage of deliveries. This information of this indicator is useful in the management of safe motherhood programmes. It serves as proxy measure for monitoring progress towards the reduction of maternal mortality. Skilled health personnel must be defined while entering in the numerator and certified by the qualified person (WHO,2006).

2.6 Availability of basic essential obstetric care (BEOC) and availability of comprehensive essential obstetric care(CEOC):

This indicators are related to the availability of essential obstetric care are recommended as assessment tools to gauge national and global progress in reduction of maternal mortality.

A basic essential obstetric care (BEOC) facility is one that performed all of the following six services(known as signal services) at least once in the previous three months: administration of parenteral antibiotics, oxytocics and anticonvulsants; manual removal of the placenta; removal of retained products (e.g. manual vacuum aspiration); and assisted vaginal delivery (vacuum extraction or forceps)(UNICEF,1997).

A comprehensive essential obstetric care (CEOC) facility refers to one that has performed surgery (caesarean section) and blood transfusion, in addition to all six BEOC services, at least once in the previous three months(UNICEF,1997). The data sources of this indictor include all public and private facilities and population census data. Service statistics like case sheets used for checking the six services in BEOC and eight functions in CEOC, are presented at least once in three months. Facility based assessments are conducted on facilities in a programme area(UNICEF,1997;Macro international,2000).

The availability of CEOC facilities disaggregated into rural and urban areas. These indicators raise the awareness on the need of availability of CEOC for the management of life threatening obstetric complications and reduce the maternal mortality. Wherever, private primary care is involved, CEOC than BEOC care, can be estimated accurately. Enumeration of private EOC facilities requires special surveys or complete facility registration. It is yet to be established the requirement of four BEOC and one CEOC per 500000 persons in different settings(WHO,2006).

2.7 Perinatal mortality rate:

This indicator estimate the number of perinatal deaths per 1000 births

The perinatal period commences at 22 completed weeks (154 days) of gestation (the time when birth weight is normally 500 g), and ends at seven completed days after birth (WHO, 2006).

Perinatal mortality rate is defined as the number of deaths of fetuses weighing at least 500 g (or, when birth weight is unavailable, after 22 completed weeks of gestation or with a crown–heel length of 25 cm or more), plus the number of early neonatal deaths, per 1000 total births. Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born. Fetal death is death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus doesn’t breathe or shows any signs of life. The duration of gestation is counted from the first day of last menstrual period and express in either completed days or completed weeks.

In the absence of information on birth weight, gestational age and crown length are included in the statistics of perinatal mortality. The numerator and denominator of all ratios and rates are restricted to the fetus or infants weighing 1000g or more.

Gestational age and body length can be of use when information on birth weight is not available. Vital registrations, birth notifications, health facility based data, population based survey, censuses and confidential enquiries are sources of information of this indicator. When hospital specializes caring women and babies with complications, the hospital mortality may not representative of birth cohort. In surveys involving women of reproductive age, details on pregnancy and birth outcomes are obtained in interviews using standardized questions. Though census provides information on stillbirths and time of deaths, this information may not be available until published. Confidential enquiries collect data on cause of death. Data on live births and stillbirth must be included with gestational age or birth weight and time of death for live born infant. A set of questions on pregnancy history, and information on number and age at death of live or stillborn infant are used to calculate the perinatal mortality in surveys. Presentation of perinatal mortality by residence, mother’s socio-economic status, place of birth, birth attendant, private/public provider, single and multiple births, may be useful to know the influence of socio-economic status on perinatal mortality and utilization of health services.

When presented in terms of prepartum and intrapartum stillbirths, early neonatal deaths (deaths in the first week) and birth-weight-specific mortality, the information, may provide insight on the quality of childbirth and neonatal services. This indicator measures the outcome of pregnancy in terms of infant. Combining this indicator with stillbirths and early neonatal deaths avoid misclassification of early deaths of live born infants as stillbirths otherwise it may lead to underreporting of early deaths. Perinatal mortality data provides information on the quality of intrapartum and postnatal care services. It also serves as alternative sensitive measure of maternal health. It is not a useful indicator to monitor the effectiveness of interventions targeted to reduce either stillbirths or neonatal deaths(WHO,2006).

2.8 Prevalence of low birth weight:

The proportion of live born babies who weigh less than 2500g

Birth weight is the first weight of the infant obtained after birth (ICD-10, 1992). For live births, birth weight should preferably be measured within the first hour of life with measurement accuracy of at least 10 g, and a correct reading technique.

Low birth weight (LBW): < 2500 g (ICD-10, 1992)

Very low birth weight: < 1500 g (ICD-10, 1992)

Extremely low birth weight: < 1000 g (ICD-10, 1992)

The sources of data of this indicator are service-based data and population based surveys. Birth weight is recorded in hospitals and presented as percentage of infants born with a birth weight weighing <2500g or in birth weight groupings (WHO, 2006). This data may not be representative of the population and should be used with caution. In some surveys, mother’s assessed size is taken into consideration and this may not permit the estimation of low birth weight. LBW should be recorded throughout the year rather than at one point of time in view of evidence of seasonal variations in the rates of LBW. Rates of LBW have been shown to depend on the food availability, epidemics and social and other causes. Presentation of LBW rates in terms of residence, place of birth, mother’s age and socio-economic state is useful. Reporting of LBW into very low or extreme LBW, weight distributions by 500g groupings, by single or multiple births and by gestational age can provide information on components associated with adverse outcomes in terms of health and costs. LBW is a summary measure of many factors such as maternal nutrition, life style and other exposure in pregnancy.

LBW is strongly associated with perinatal mortality and morbidity, infant mortality, disability and disease in later life.LBW is a strong predictor of an individual baby’s survival, an important measure of infant health and a surrogate measure of infant morbidity and risk of mortality in the population. Adequate measures are taken to ensure accurate reading. LBW is not considered as a measure to assess the rate of preterm birth. Inability to differentiate between preterm birth and restricted fetal growth and failure to assess the entire range of gestational and fetal growth invalidate the LBW as a proxy measure for impaired fetal growth. Assessment of comparative size may not be adequate and institutional data may not reliable as most of the births occur at home (WHO, 2006).

2.9 Prevalence of positive syphilis serology in pregnant women:

The proportion of pregnant women aged 15–24 years attending antenatal clinics with a positive serology for syphilis.

The sources of data of this indicator include sentinel surveillance approaches and community based surveys (WHO, 1999, 2000 and 2002). Pregnant women are tested for syphilis during antenatal care, though data is useful, the quality of reporting and testing is questionable. Samples may not be representative of all pregnant women. Syphils serology may not correlate with sexually transmitted infections (STI) prevalence. Community based survey require large sample. Voluntary testing introduces participation bias in the data. Data specific for age, residence, socio-economic status and parity may be of use than total prevalence. It is a surrogate indictor to assess the burden of STI and serve as a measure to monitor the progress towards reducing the burden of STI. In settings of low prevalence of syphilis, this infection (syphilis) is considered as an early indicator of the spread of HIV infection and biological marker for high-risk sexual practices. Only low risk pregnant women visit the antenatal care and estimated magnitude may be low. Infertile women and non-pregnant women are excluded in the data. The data may not represent overall population. The proxy value of this indicator in estimating STI prevalence is limited (WHO, 2006).

2.10. Prevalence of anaemia in women:

The proportion of women of reproductive age screened for hemoglobin levels who have levels below 110 g/l (pregnant women) and 120 g/l (non-pregnant women).

Women of reproductive age refer to all women aged 15-49 years. Anaemia is a disorder characterized by a blood haemoglobin concentration lower than the defined normal level, and is usually associated with a decrease in the circulating mass of red blood cells. Nutritional anemia includes iron, folate and vitamin B12 deficiencies. Anemia can cause death because of heart failure, shock or infection due to impaired capacity to support vital functions. The cut-off level for anemia for non-pregnant women is < 120 g/l, and for pregnant women < 110 g/l(WHO, 2006).

Health facilities and population based surveys are the sources of information for this indicator. Cyanmethaemoglobin is considered as gold standard for estimation of haemoglobin concentration (Sari et al., 2001) Hemocue method, clinical examination, hemoglobin colour scales are also used for screening anemia in surveys(Sari et al., 2001; Program for appropriate technology in Health,1996; Dusch et al., 1999). Prevalence of anemia is reported into mild (90–110 g/l), moderate(70–90 g/l) and severe(<70g/ l). It may also be presented by pregnant, lactating, non-pregnant and non-lactating women and by age, parity, trimester of pregnancy and geographical location. This indicator is useful to screen women with iron deficiency and can be used as a surrogate marker for assessing the nutritional status and as a direct measure to find the health status.

Population based survey methods can be used to assess iron deficiency; to study the prevalence of anemia; to identify high-risk groups; to test the efficacy of iron deficiency treatment programmes; and to advocate food fortification programmes. Data should contain source and, method of estimation of hemoglobin. Hemoglobin values should be adjusted for the altitudes if the data is presented for highland dwellers. Data from antennal care should be interpreted with caution. No single hemoglobin value was unable to differentiate between anemic and non-anemic and, nutritional deficient and sufficient (WHO,2006).

2.11 Percentage of obstetric and gynecological admissions owing to abortion: The proportion of admissions for (spontaneous or induced) abortion-related complications to service delivery points providing inpatient obstetric and gynaecological services, among all admissions (except those for planned termination of pregnancy).

Abortion-related complications occur due to spontaneous or induced abortion. Induced abortion may be attempted by women themselves (self-induced), by clandestine/illegal providers or by licensed providers offering. Abortion is the termination of a pregnancy before the fetus has attained viability, i.e. become capable of independent extra-uterine life. Induced abortion is the deliberate termination of a pregnancy before the fetus has attained viability i.e. become capable of independent extra-uterine life. Spontaneous abortion is the spontaneous termination of a pregnancy before the fetus has attained viability i.e. become capable of independent extra-uterine life. This is also known as miscarriage (WHO, 1979 and 1997).

Hospital records can give information on this indicator. Data on abortions is not reported in many countries due to stigma associated with it. This indicator measures the case-load or cost or resource demand imposed on the medical system by complications of abortion. It can serve as a process indicator for assessing the utilization of services. This measure cannot be used to assess trends or changes and there is a need to collect data from large institutions with big caseloads for deriving the indicator (WHO, 2006).

2.12 Prevalence of women with genital mutilation: The proportion of women interviewed in a community survey who report having undergone genital mutilation

Female genital mutilation (FGM) is the result of all procedures that involve the partial or total removal of external female genitalia or other injury to the female genital organs, whether for cultural or any other non-therapeutic reason. These include: Type I – excision of the prepuce, with or without excision of part or all of the clitoris; Type II – excision of the clitoris with partial or total excision of the labia minora; Type III – excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening (infibulation); Type IV – pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above (WHO, 2000).

Data sources include community surveys or census questionnaires. Repeated surveys would be able to detect trends. Inclusion of women in the age group of 15-49 is preferred. Data can be disaggregated into age, residence and ethnic group. This indicator provides the base line information for the policy makers and can be helpful in evaluating subsequent monitoring and evaluation. This indicator is correlated with reproductive health. Women may not feel comfortable to reveal the information. Some times, FGM is performed on babies and in those situations, women may not be aware that they have undergone FGM and also about the type of FGM has been performed. This indicator may not be useful where FGM is not practiced. Definitions are not universal and representativeness of this measure depends on the representativeness of the sample used and willingness of the women to respond to the question on FGM (WHO, 2006).

2.13 Prevalence of infertility in women:

The proportion of women of reproductive age (15–49 years) at risk of becoming pregnant (not pregnant, sexually active, not using contraception and not lactating) who report trying for a pregnancy for two years or more.

Women of reproductive age refer to all women aged 15–49 years. Women at risk of becoming pregnant refer to those who are not pregnant, sexually active, not using contraception and not lactating.

The source of data are community and health surveys. In community surveys, couples answer the details on sexual practices, contraceptive use, previous births and lactation. There is a need to identify the difference between involuntary or voluntary childlessness in health surveys. Data is disaggregated into age, ever been pregnant and length of time trying for pregnancy. This indicator assesses the level of infertility in a community. Infertility as measure of reproductive morbidity is used as marker of progress towards improved reproductive health(UNPF, 1996). The causes of infertility are genital tract infections, congenital errors of reproduction and hormonal factors. Secondary infertility is caused by complications and sequelae following sexually transmitted diseases. Level of secondary infertility can serve as surrogate marker for long-term sequel of sexually transmitted Infections. There is often a chance of misclassifying early pregnancy loss as no pregnancy. Response bias is taken into consideration in reporting estimations, as the questions used for response are sensitive in nature. Inclusion of all women of reproductive age may not be applicable, in countries, where high percentage of people are unmarried and opt for periodic voluntary childlessness. However, the cause of infertility could be due to both female and male but women are always blamed.

2.14 Reported incidence of urethritis in men:

The proportion of men aged 15–49 years, interviewed in a community survey, who reported having one or more episodes of urethritis in the previous 12 months.

Urethritis is discharge from the penis, with or without a burning sensation or pain while passing urine. Discharge can be thick or thin and either clear(like mucus) or coloured green, yellow or white).Any discharge that contains blood is usually not indicative of urethritis. An episode is the occurrence of symptoms, either for the first time ever or at least five days after the disappearance of previous symptoms. The recall period of 12 months refers to the last 12 months and not the previous calendar year(WHO,2006).

Community surveys are used for collecting the data. A two stage cluster sampling technique with a 12 month recall period is used. Survey areas, proportional to the size, in the first stage and in the second stage, households with probability inversely proportional to the area size, are selected. Men of 15- 49 years are interviewed to know the prevalence of urethritis. Data is collected in private, assuring that their data will not be made public. Data is disaggregated into age, residence and geographical area. This indicator is useful to assess the burden of STI in adult male population and also to study the impact of preventive services for STI. Discrepancies between observed and reported cases were observed. Recall bias may cause underreporting of the prevalence (Klouman et al.,2000). Efforts have to be made to minimize the recall bias. A symptomatic gonococcal or chlamydial infection in males limits the applicability of this indicator (Watson-Jones et al., 2000). Self reported symptoms should be interpreted with caution in assessing the impact of preventive and treatment services (WHO, 2006).

2.15 Prevalence of HIV infection in pregnant women:

The proportion of blood samples taken from women aged 15–24 years that test positive for HIV during routine sentinel surveillance at selected antenatal clinics. Prevalence of HIV infection in pregnant women =

Positive HIV test: A sample is considered positive when, on single application of the test, evidence of past HIV infection is determined. This standard screening test for HIV is Enzyme linked immunosorbent assay.

The sources of the data are sentinel surveillance and population based seroprevalence. Sentinel surveillance identify HIV infection from the blood of persons given for other purposes in specific settings that provide service to them. These specific setting include blood blanks, sexually transmitted infection clinics, military recruitment programmes and antennal clinics. The data from these settings may not be representative of the general population. Household surveys cover large population but cost intensive. In both settings, requirement of informed consent introduces non-participation bias. Data is presented in terms of age, occupation, mobility and residence.

An understanding of the national picture requires an understanding the patterns and trends on HIV in sub populations. This indicator is surrogate measure for HIV incidence. Incidence is the preferred indicator to monitor the course of the HIV epidemic and the impact of interventions as the prevalence data reflect infections acquired over a number of years. Representation of males in sentinel data should be increased as evidence showed higher infection rate among females than males. Sentinel surveillance is useful to monitor the trend in 15-24 years and may not have utility in assessing trends in incidence and prevalence of HIV in adult population. For observing epidemiological trends, monitoring trends in high risk behaviour like median age at first intercourse (among women and men age 15–24 years); percentage of women/men who have had sex with a non-marital, non-cohabiting partner in the previous 12 months; and percentage of women/men who used a condom when having intercourse with a non-marital, non cohabiting partner, must accompany and supplement the surveillance of HIV prevalence(WHO,2006) .

2.16 Knowledge of HIV-related preventive practices:

The percentage of survey respondents who correctly identify all three major ways of preventing sexual transmission of HIV, and who also reject all three major misconceptions about HIV transmission or prevention.

The three major ways of preventing sexual transmission of HIV are:

(a) having no penetrative sex;

(b) using a condom; and

(c) limiting sexual activity to one faithful, uninfected partner.

The three major misconceptions about HIV transmission or prevention are:

(a) not understanding that a healthy-looking person can carry the AIDS virus; and

(b) two other major misconceptions to be determined in the local cultural context.

Inclusion criteria include all aged 15-49 years and only those who satisfy the definitions for complete knowledge and lack of misconceptions in the numerator. The data source of indicator is population based household surveys. Two instruments namely UNAIDS/MEASURE Evaluation General

Population Survey; and HIV/AIDS module of the Demographic and Health Surveys (HIV/AIDS Survey indicators database ) were developed for generating consistent and uniform data. Most of the data from developing countries on knowledge of HIV prevention were obtained using Demographic and Health Surveys. For getting estimates, sample should be designed to represent the groups of interest such as male, female, urban, rural, people of different socio-economic status and adolescents. For a single estimate, a minimum sample of 500 are required and for national estimates, data on 3000 men and 3000 women, would be adequate. This indicator is disaggregated by sex and age group and by urban/rural residence, major administrative divisions and major socio-economic status. To lay emphasis on HIV/AIDS programmes for youth populations, this indicator is reported separately for the 15-24 age groups and for 15-19 age groups. This indicator assesses the knowledge HIV prevention practices in the investigated populations and helpful in behavior modification.

Misinformation dimension is added to this indicator to exercise discrimination in identifying individuals and population who are susceptible to adopting behavior that modify the chance of HIV transmission. Questions used in the surveys should be validated in different languages and culture contexts .If youth is the priority, the school going adolescents should be included, if knowledge on HIV transmission is sought, then along with knowledge assessment, the trends in the indicators of behavior should be included(WHO,2006).

3. Obstetric history of women: Obstetric history is taken to arrive at diagnosis; assess the health risk of patients; and to prepare management plan. A comprehensive history is recorded at the time of pregnancy evaluation or at the initial antenatal visit. The following details are collected.

3.1. Identification data:

It consists of details like patient name, age, race, gravida, parity, last normal menstrual period, expected date of delivery and gestational age. Gravid means number of pregnancies. Parity refers the outcome of pregnancies. Generally, menstrual cycle is of 28 days. The first day of the last menses is the last normal menstrual period (LNMP).On an average, full term pregnancy lasts 266 from conception to delivery. The interval between LNMP and expected date of delivery is 14 days. If these 14 days added to the ovulation age, it will give gestational age i.e. 280 days or 40 weeks. Expected date of delivery is 280 days from the start of last menstrual period. This is known as Naegele’s rule. Modified Naegele’s rule is adding 9 months 7 days to the first day of last menstrual period.

3.2. Chief complaint:

This describes the symptom or problem for which the patient came to see the doctor.

3.3. History of presenting illness:

The onset, nature, aggravating or reliving factors of complaint are discussed with the patient by the doctor.

3.4. History of present pregnancy:

The details from the diagnosis of present pregnancy to the onset of complaints, are enquired and recorded.

3.5. Past Obstetric history:

The details of previous pregnancy in chronological order are recorded. The information on the following details is enquired to assess the possibility of recurrence of previous problems in the present pregnancies. The details collected includes date of delivery, location of delivery, duration of gestation, type of delivery, duration of labour, type of anesthesia, maternal complications, newborn weight and gender, fetal and neonatal complications.

3.6. Gynecology history:

History of inter menstrual bleeding, menorrhagia or dysmenorroea, sepsis or sexually transmitted diseases and cervical smear test results are enquired.

3.7. Contraceptive history:

History of oral contraceptive and intrauterine device usage is enquired. Their usage has been shown to cause pregnancy loss, birth defects, infection and premature delivery.

3.8. Medical history: Presence of disorders like diabetes, hypertension and renal disease is enquired as they will affect the pregnancy outcome.

3.9. Surgical history: If patient has undergone surgery, the details like date, hospital, surgeon and complications, are recorded.

3.10. Social history:

History of alcoholism, smoking, substance abuse are recorded and managed. Contact or exposure to animals is also recorded. Details of work and lifestyle may affect the pregnancy and exposure to solvents (carbon tetra chloride) or insulators, for example, polychlorobromine may lead to teratogensis or hepatotoxicity.

3.11. Drug and Allergy history:

Allergy to food and modification are enquired in order to avoid their exposure. Drug intake is also recorded. Some drugs contradictory to pregnancy should be stopped and some drugs intake must maintained in different form or at different dose.

3.12. Family history: Patients are asked on the history of congenital abnormalities, hypertension, diabetes and, tuberculosis in their family members and documented, as they are passed on to the patient putting them at high risk to develop the same problem during pregnancy. Patients are screened for the presence of diseases like diabetes.

3.13. Systemic review:

Symptoms experienced by the patients during the pregnancy in other body systems such as cardiovascular, respiratory, gastro intestinal, urinary, nervous system, musculoskeletal and dermatology, are enquired and recorded.

3.14. Summary:

At the end of the history, a summary stating briefly the details of the patient such as age, gravid, parity, period of gestation, chief complaints, positive and negative history, is prepared. A list on possible differential diagnosis and clinical signs is prepared (Minkoff,1983; Ibrahim, 2009; Geekymedics, Konar,2014; Jacob,2012).

3.15. Signs:

Presence of certain signs should be looked during physical examination. These signs in different organs include 1) Hands: Koilonychia (hollow nail or spoon nail) may indicate the iron deficiency anemia. 2) Eyes: Pallor (pale appearance) conjunctiva may suggest anemia; yellow discolouration of sclera may indicate jaundice; and presence of exoptholmos (protrusssion of the eye ball(s) suggest thyrotoxicosis(excessive thyroid hormone). 3) Mouth: Pale mucous membrane and angular stomatitis (sore mouth) may suggest anemia; glossitis(inflamed tongue) may indicate folate deficiency; and presence of central cyanosis(bluish discolouration) is a sign of heart disease. 4) Thyroid: enlarged thyroid may indicate increased metabolism in pregnancy. 5) Legs: Odema (swelling due to excess of watery fluid) in hands and feet is a normal feature in pregnancy, whereas oedema in face and sacral area(back) is considered as an aberration. Odema sign can be observed by pressing the finger on tibia for 10 seconds. 6) Abdomen: Presence of striae gravidarum (scarring of the skin in abdominal region due to weight gain) is observed in pregnancy, whereas presence of striae albicans (white furrow) may be considered as sign of previous pregnancy. If scars are (surgical or laproscopic) present it type, site, length and signs of infection are documented. Incisional hernia is observed when facial tissue fail to heal and close after laprotomy(a surgical incision in the abdominal cavity in preparation of surgery) particularly in caesarian deliveries. Abdomen is palpitated to determine abdominal wall is soft or rigid.

Pregnant women abdomen wall is soft and intermittently harden. Extreme tenderness below umbilicus was observed on palpitation in women with peritoneal irritation and ectopic pregnancy. 7) Uterus: Palpitation of uterus reveal whether it is contraction or not contracting (soft). If uterus is not contracting it indicates that women at risk of excessive bleeding or hemorrhage. When uterus is not of term size, liver, epigastric and loin tenderness can be observed. Measurement of distance (cm) between the fundus of uterus to the top of symphysis pubis determine the uterus size and measuring distance (cm) between the fundus and umbilicus determine the position of uterus. The number of fetus is confirmed by palpitation of fetal poles in the uterus. Each fetus two poles and presence of more than two poles indicates multiple pregnancy (Ibrahim, 2009).

Summary

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 relating to the reproductive system and to its functions and processes.

Scope of reproduction health ranges involves information, education and communication, special services to adolescents, discouraging practices like genital mutilation, prevention of gender violence and sexually transmitted diseases, termination of unwanted pregnancies and promotion of safe mother hood an family planning programmes.

Millennium summit in the year 2000, set 8 Millennium development goals. The fifth goal advocated reduction of maternal mortality achievement of universal access to reproductive health care.

Various international organizations have consented for 17 reproductive health goals. They are total fertility  rate, contraceptive prevalence, maternal mortality ratio, antenatal care coverage, births attended by  skilled health personnel, availability of basic essential obstetric care  and availability of comprehensive essential obstetric care, perinatal mortality  rate, prevalence of low birth weight, prevalence of positive syphilis serology in pregnant women,  prevalence of anaemia in women, percentage of obstetric and gynaecological admissions owing to  abortion, Reported prevalence of women with genital mutilation, Prevalence of infertility in women, Reported incidence of urethritis in men, Prevalence of HIV infection in pregnant women and Knowledge of HIV-related preventive practices.