15 Reproductive health and Anthropology

Mary Grace ‘D’ Tungdim

Contents:

1.  Introduction

2.  Definition and scope of reproductive health

2.1 Reproductive health indicators

3.   Reproductive health: A life cycle approach

3.1 Maternal health

3.2 Early pregnancy and childbirth

4.  Tools for family planning

5.  Reproductive health: Indian Scenario

6.  Men’s role in reproductive health

7. Reproductive Health and Anthropology

Summary

Learning Objectives:

1.  To study the definition and scope of reproductive health

2.  To understand the indicators of reproductive health

3.  To study the relationship of reproductive health and anthropology

1. Introduction

Reproductive health is an indispensable ingredient of health and a major determinant of human development. Reproductive health plays an important role in the health needs of a population. The concept of reproductive health recognizes the diversity of the special health needs of women before, during and beyond child bearing age, as well as the needs of men. The World Health Organization (WHO) defines reproductive health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes”. This definition implies all people should have:

• Satisfying and safe sex life
• The capacity to reproduce as well as the freedom to decide if, when, and how often to do so; and
• Access to appropriate healthcare services that enable women to go safely through pregnancy and childbirth, thus providing couples the best chance of having healthy infants.

   Maternal health contributes most of the reproductive health. Maternal death is one of many preventable perils. Maternal death including reproductive health can only addressed by empowering women and girls and protecting their health, wellbeing and rights, including their productive rights.

The success of the new Sustainable Development Goals(SDGs) depends on whether we succeed at ensuring all women and girls are healthy, are able to exercise their human rights, enjoy equal opportunities and hold the key to their own futures so that they thrive and help transform the world. The human population size of the world is determined by three demographic phenomena- fertility, mortality, and migration.

2. Definition and scope of reproductive health

Reproductive health is a lifetime concern for both women and men, from infancy to old age. Evidence shows that reproductive health in any of these life stages has a profound effect on one’s health later in life. UNFPA in 2015 continued to support programmes tailored to different challenges people face at different times in their lives, including comprehensive sexuality education, family planning, antenatal and safe delivery care, services to prevent sexually transmitted infections, including HIV, and services facilitating early diagnosis and treatment of reproductive illnesses, including breast and cervical cancer.

The concept of reproductive health 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).

2.1 Reproductive health indicators

One of the Millennium Development Goals is advocated towards reducing maternal mortality and achieving universal access to reproductive health care. WHO and partners (including UNFPA) conducted considerable work to define indicators of sexual and reproductive health. In 1998, UNFPA published indicators for population and reproductive health programmes (UNFPA, 1998). In 1999 and 2001, two interagency meetings defined a shortlist of 17 indicators for global monitoring, based upon recommendations made at the fifth-year follow-up of ICPD (ICPD+5). A WHO document providing guidelines for data collection, analysis, and interpretation of these indicators was recently published (WHO, 2006). The 17 indicators address the main aspects of sexual and reproductive health and provide a list from which indicators can be selected. The reproductive health indicators are:

1.      Total Fertility Rate (TFR)

2.      Contraceptive Prevalence Rate (CPR)

3.      Maternal Mortality Ratio (MMR)

4.      Antenatal Care Coverage

5.      Percent of Births Attended by Skilled Health Personnel

6.      Availability of Basic Essential Obstetric Care

7.      Availability of Comprehensive Essential Obstetric Care

8.      Perinatal Mortality Rate (PMR)

9.      Low Birth Weight Prevalence

10.  Positive Syphilis Serology Prevalence in Pregnant Women

11.  Prevalence of Anemia in Women

12.  Percent of Obstetric and Gynecological Admissions Owing to Abortion

13.  Reported Prevalence of Women with FGC

14.  Prevalence of Infertility in Women

15.  Reported Incidence of Urethritis in Men

16.  HIV Prevalence among Pregnant Women

17.  Knowledge of HIV-related Prevention Practices

These indicators, however, are not specific for measuring “access”, nor do they provide a framework to address all aspects of sexual and reproductive health systematically. These indicators are modified according to local contexts, both in developing and developed country settings. Further it was felt that a life-course approach to sexual and reproductive health was the need of the hour, so there is a necessity for determining the sexual and reproductive health needs of older women and older men, and recommended special attention to the needs of marginalized groups. In the year 2006, as per the request of the UN to the Inter-Agency Expert Group (IAEG) to identify relevant indicators, the IAEG proposed a core set of indicators for the new target of universal access to reproductive health, which includes contraceptive prevalence rate, unmet need for family planning, adolescent birth rate, and antenatal care attendance.

3. Reproductive health: A life cycle approach

Reproductive health is a lifetime concern for both women and men, from infancy to old age. Taking a life course approach to the study of reproductive health involves investigation of factors across life and also across generations. Evidence shows that reproductive health in any of these life stages has a profound effect on one’s health later in life. UNFPA supports programmes tailored to different challenges people face at different times in their lives, including comprehensive sexuality education, family planning, antenatal and safe delivery care, post-natal care, services to prevent sexually transmitted infections (including HIV), and services facilitating early diagnosis and treatment of reproductive health illnesses (including breast and cervical cancer).

To support reproductive health throughout the life cycle, services across a variety of sectors must be strengthened, from health and education systems to even transport systems – which are required to ensure that health care is accessible. And all efforts to support sexual and reproductive health rely on the availability of essential health supplies, such as contraceptives, life-saving medicines and basic medical equipment. As per the life course approach women’s reproductive history can serve as an excellent prognosticator of a later chronic disease. Bhasin & Kapoor (2013) concluded that there is a clear relationship between cardiometabolic health and pregnancy history. They further added that life course approach and knowledge about obstetric history can be applied to reduce the global chronic burden of pregnancy related maternal death.

3.1 Maternal health

Maternal health is another area where much more needs to be done. Poor women still die in huge numbers from the complications of pregnancy and childbirth. According to UNFPA, 920 women die for every 100,000 live births in sub-Saharan Africa. However, these numbers are, at best, only rough estimates gleaned from hospital statistics. Many women go uncounted because they never reach the health-care system for treatment in the first place.

Source: http://www.economist.com/node/3150560

Good ante-natal health care is vital to reduce maternal sickness and death. So are cheap and simple drugs, such as oxytocin, to prevent haemorrhaging during birth. Trained midwives (or “birth attendants” as they are known in medical parlance) help, too. And so do local emergency obstetric centres that can handle complicated deliveries. Some countries like Sri Lanka have managed to cut maternal mortality by careful spending on such measures. The challenge is to translate these successes to other places.

Source:http://ihmrsynergy.blogspot.in/2011/11/why-are-womens-health-outcomes-in-india.html

    3.2 Early pregnancy and childbirth

The leading cause of death for 15– 19-year-old girls globally is complications from pregnancy and childbirth. Some 11% of all births worldwide are to girls aged 15–19 years, and the vast majority of these births are in low- and middle-income countries. The UN Population Division puts the global adolescent birth rate in 2015 at 44 births per 1000 girls this age – country rates range from 1 to over 200 births per 1000 girls (SDG Indicators, 2016). One of the specific targets of the health Sustainable Development Goal (SDG 3) is that by 2030, the world should ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes. To support this, a proposed indicator for the Global strategy for women’s, children’s and adolescents’ health is the adolescent birth rate.

Better access to contraceptive information and services can reduce the number of girls becoming pregnant and giving birth at too young an age. Laws that specify a minimum age of marriage at 18 and which are enforced can help.

Girls who do become pregnant need access to quality antenatal care. Where permitted by law, adolescents who opt to terminate their pregnancies should have access to safe abortion.

4. Tools for family planning

Austin Ruse, the president of the Catholic Family and Human Rights Institute (C-FAM), an American Christian lobby group, argues that the shift in talk from fertility control to reproductive rights and services is just code for making abortion universally available. He regards this as wrong, and believes that the ICPD plan of action and those agencies which support it—particularly UNFPA—should be opposed at every turn by a growing coalition of “pro-family” groups worldwide.

UNFPA, not surprisingly, has a different view. Thoraya Obaid, its head, reckons that those who oppose the ICPD plan of action are not just against legalizing abortion, but are fighting against women’s rights in general. She points to the text of the plan, which states that abortion should never be promoted as a form of family planning and that women should be helped to avoid abortion through better access to contraception.

However, trouble lies in the plan’s statement that abortion policy should be up to national governments to decide. Since 1994, more than a dozen countries have liberalized their laws on abortion. Surveys from hospitals in Ethiopia, Uganda and Kenya suggest that anywhere from 20-50% of maternal deaths are due to complications resulting from unsafe backstreet abortions. But these numbers are challenged by the opponents of abortion, who argue that it is a rare phenomenon in the developing world, and that legalizing it will make it more common. Today’s battles over abortion, abstinence and condoms are casting a pall over the field, and complicating what is already a formidable task. Making sex safer and reproduction less risky in the 21st century requires all the tools to hand. Policies that restrict people’s choices should not be a fact of life.

Sexual and reproductive health was given an international consensus definition at the International Conference on Population and Development (ICPD) in 1994. A plan to achieve “reproductive health and rights for all” by 2015 was drafted at the International Conference on Population and Development (ICPD). The plan was wide-ranging—from more contraception and fewer maternal deaths to better education for girls and greater equality for women.

Besides these targets, the ICPD plan also aimed to change the way those at the sharp end of making policy and delivering services. It wanted to move away from focus on family planning (and, by extension, government policies on population control) towards a broader view of sexual health, and systems and services shaped by individual needs. It was also felt that sexuality and reproduction are vital aspects of personal identity and are fundamental to human well being fulfilling relationship within diverse cultural contexts. Sometimes, a high birth rate is a result of people wanting large families. But often it is due to a lack of affordable contraception. UNFPA estimates that 137m women who want to use contraception cannot obtain it.

Though contraceptives are not regular requirements for reproductive health, one is forced to use them to avoid pregnancy or to delay or space pregnancy. Medical termination of pregnancy is legalized in our country. MTP is generally performed to get rid of unwanted pregnancy due to rapes, casual relationship, etc., as also in cases when the continuation of pregnancy could be harmful or even fatal to either the mother, or the foetus or both.

Pelvic Inflammatory Diseases (PIDs), still birth, infertility are some of the complications of diseases or infections transmitted through sexual intercourse which are called Sexually Transmitted Diseases (STDs). Early detection of these diseases facilitate better cure for these diseases. Avoiding sexual intercourse with unknown/multiple partners, use of condoms during coitus are some of the simple precautions to avoid contracting STDs.

Various methods are now available to help such couples who are unable to conceive or produce children even after 2 years of unprotected sexual cohabitation. In Vitro fertilization followed by transfer of embryo into the female genital tract is one such method and is commonly known as the ‘Test Tube Baby’ Programme. Various contraceptive options are now available, such as natural, traditional, barrier, IUDs, pills, injectables, implants and surgical methods.

5. Reproductive health: Indian Scenario

In India, reproductive health status of man and woman is inextricably bound up with social, cultural, and economic factors that influence all aspects of lives. It has consequences not only for women themselves but also on the well-being of their children including the functioning of households, and the distribution of resources. The tribal women fulfil multiple productive functions in addition to bearing children and performing household chores. Ironically, despite the agricultural innovations, it has not benefited rural women, who still have to perform the conventional household work and at the same time be engaged in agricultural and other menial works (Bhardwaj & Tungdim, 2010). Women are obliged to resume work even before they have fully recovered from the process of childbirth.

Therefore, Reproductive health in a society forms a crucial part of general health. India was amongst the first countries in the world to initiate to the programme “family planning” initiated in 1951. Improved programs covering wider reproduction-related areas are currently in operation under the popular name ‘Reproductive and child health care (RCH) program’. Health and education of young people and marriage and child bearing during more mature stages of life are important attributes to the reproductive health of a society.

Maternal nutrition during pregnancy is also essential for good reproductive performance and maintenance of a pregnant women’s health and that the diet should be with adequate protein and calories. The other area which needs to be focussed in reproductive health is that till date there are many tribal communities where majority of childbirths occur without the help of a skilled assistant (defined as a mid wife, nurse trained as mid wife, or a doctor) at some or in other non-hospital settings. Presence of a professional attendant at each birth can lead to a marked reduction in maternal mortality and morbidity.

6. Men’s role in reproductive health

Before the advent of the oral contraceptive pill, men were more involved in family planning and other aspects of reproductive health. Then, if a couple wished to practice family planning, they were largely limited to withdrawal, periodic abstinence, and condom use, all practices which require man’s participation. Hormonal methods for women and the subsequent development of IUDs and modern surgical sterilization fostered the development of a family planning services community focused upon women rather than men. The shift in focus on men’s reproductive health was influenced by the 1994 Cairo (ICPD) Action Plan to promote gender equality and equity, empower women, and improve family health in society.

Changing and improving the way in which men are involved in reproductive health can only have a positive impact on women’s, men’s, and children’s health. Educating and counseling men about contraceptive choices is essential if they are to be supportive of women’s reproductive health. Research on new male contraceptive methods must continue if the bias of women shouldering the major responsibility for contraception is to be eliminated (Bustamante-Forest and Giarratano, 2004). The challenge is now to increase the degree of male responsibility for family planning by expanding services in ways which protect the reproductive health of both men and women, and by encouraging greater sensitivity to gender issues.

Obstacles include men’s reluctance to use services, lack of knowledge among men about their own and women’s sexuality, lack of communication by men about sexuality in their relationships, male beliefs in sexual myths, health providers’ and false assumptions and generalizations about men. There is the need to encourage men to support women’s contraceptive choices, to increase communication between partners, to increase the use of male methods, to improve men’s behavior for the prevention of STDs, to address men’s reproductive health needs, and to encourage men to become more aware of related family issues (Ndong and Finger, 1998).

Indian tribal men’s lack of participation in reproductive health not only damages their own health, but also contributes to the reproductive ill health of their female partners and children. In India the involvement of men in such matters is a new concept. Men are recognized to be responsible for the large proportion of reproductive ill health suffered by their female partners. Lack of knowledge, non availability of acceptable contraceptives and lack of services with quality of care deter men from sharing the responsibility in reproductive health matters. Misinformation regarding male sexuality and limited availability of scientific data contributed less involvement of men in reproductive health.

Thus, various strategies are implemented to increase men’s awareness of reproductive health and the accessibility of products and services. These strategies include: 1) increasing contraceptive options for men; 2) supporting women’s contraceptive use; 3) improving sexual behavior and safe sex practices; and 4) narrowing the gender gap for better fertility control. Moreover, extensive research is required in order to understand men’s perceptions and needs about fertility regulation and sexual behavior as well as services development (Puri et al., 1999).

7. Reproductive Health and Anthropology

Anthropological work on reproductive health draws upon disciplines of public health, demography, biosocial approaches, cultural and historical approaches, etc. Research on reproductive health within medical anthropology encompasses people’s emic perspectives on all matters related to sexuality and reproductive processes and functions. Some of the earliest works to describe ethno-physiological understandings include Ashley Montagu’s (1949) work on understandings of conception, fetal development, and embryology among Australian indigenous peoples. Likewise, Malinowski’s (1932) work in the Solomon Islands and Margaret Mead’s (1928) work in Samoa may be seen as antecedents to modern work on the subject of sexuality which is a component of reproductive health.

Early work on reproductive customs include Ford’s (1964) comparative work listing beliefs and practices in 64 societies. In the last 30 years studies focusing upon reproductive health have grown exponentially. Concern over the issue of world population growth in the late 1960s and 1970s spurred increased interest among anthropologists toward involvement into population issues and reproductive.

Kapoor & co-workers (2012) with the help of anthropometry found significant association of low birth weight (LBW) newborns with maternal nutritional status and age. This further highlights the importance of maternal health and the significant role of anthropology in reproductive health.

Summary

Reproductive health is an indispensable ingredient of health and a major determinant of human development. Reproductive health plays an important role in the health needs of a population. The concept of reproductive health recognizes the diversity of the special health needs of women before, during and beyond child bearing age, as well as the needs of men. World Health Organization (WHO) defines reproductive health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes”.

Reproductive health is a lifetime concern for both women and men, from infancy to old age. One of the Millennium Development Goals is advocated towards reducing maternal mortality and achieving universal access to reproductive health care. International agencies consented for 17 indicators to monitor the reproductive health goals. It is also a matter of concern for early pregnancy and childbirth as it the leading cause of complications and death for 15– 19-year-old girls globally. Medical termination of pregnancy is legalised in our country and is generally performed to get rid of unwanted pregnancy due to rapes, casual relationship, etc., as also in cases when the continuation of pregnancy could be harmful or even fatal to either the mother, or the foetus or both.

India was the first nation in the world to initiate family planning at national level to attain a reproductively healthy society. Till today, reproductive health status of man and woman in India is inextricably bound up with social, cultural, and economic factors that influence all aspects of lives. It has consequences not only for women themselves but also on the well-being of their children including the functioning of households, and the distribution of resources.

Before the advent of the oral contraceptive pill, men were more involved in family planning and other aspects of reproductive health. Men have a pivotal role in the reproductive health of women since the advent of STDs including HIV and AIDS. Anthropologists have ventured in the field of reproductive health since the early 19th century. Anthropological work on reproductive health draws upon disciplines of public health, demography, biosocial approaches, cultural and historical approaches, etc.