Global Health Challenges Social Analysis 76: Lecture 11

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Global Health ChallengesSocial Analysis 76
Lecture 11
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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services
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Sexual and Reproductive Health Definitions

• Consequences of sex in adults STDs, maternal
  causes, HIV, Hepatitis B, Human Papilloma Virus
• Consequences of sex in adults and children
  adding congenital anomalies, birth asphyxia,
  birth trauma, and other conditions arising during
  the perinatal period.
• Conditions of the reproductive organ systems
  STDS, maternal causes, reproductive cancers
• Conditions managed through reproductive health
  services all maternal and child causes.
• Conditions arising in the reproductive age-groups
  (15-44).
• Health problems predominantly affecting
  reproductive age-groups.

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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services
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Population Explosion and Control
Early 1960s, growing concern in high-income
countries that population growth in developing
countries would lead to a total world population
beyond the earths environmental carrying
capacity. During 1970s and 1980s, major
investments by US and other Western donors in the
development of contraceptive technologies and the
delivery of contraceptive services to developing
countries. Spectacular fertility declines in
many countries beyond what was expected due to
income growth or increases in educational
attainment.
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Cairo Conference 1994
At the decennial International Population and
Development Conference in Cairo in 1994, the
population community favoured a major policy
shift from a focus on population control to the
delivery of reproductive health services
including options for fertility regulation. One
interpretation is that the population community
was captured by the health community.
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Cairo Agenda

• Eight target areas were identified
• Unplanned pregnancy and unsafe abortion
• Maternal mortality and morbidity
• Reproductive tract infections including STDs
• HIV/AIDS
• Reproductive tract cancers
• Female genital mutilation and gender based
  violence
• Infertility
• Menopause

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10 Years After Cairo
Huge decline in policy attention in population
control driven by declines in TFR and Cairo
agenda change Reproductive health as an
international political agenda has lost some of
its prominence because of US and conservative
states (Iran, Vatican) antagonism to components
of the agenda. Reproductive health was not
included as a specific goal in the Millennium
Development Goals although reducing maternal
mortality was one of eight goals. 2004 many
reflections and analyses in the literature.
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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services Challenges and Controversies
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Maternal Mortality

• Three measures of maternal mortality
• Maternal mortality ratio number of maternal
  deaths per 100,000 live births
• Maternal mortality rate number of maternal
  deaths per 100,000 women aged 15-49
• Lifetime risk of maternal death cumulative
  probability of death from a maternal cause
  between 15 and 50.

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Maternal Causes

• Haemorrhage prepartum, intrapartum and
  postpartum
• Sepsis systemic infection
• Hypertensive disorders or pregnancy
  pre-eclampsia, eclampsia
• Obstructed labour
• Unsafe abortion
• Other

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Low Birth Weight
Approximately two-thirds of perinatal conditions
are due to low birth weight, defined as a birth
weight less than 2500 grams. Two causes of low
birth weight small for gestational age and
preterm. In developing countries, largest
component (60) of low birth weight is small for
gestational age. Risk factors include maternal
nutritional status, diabetes, hypertension,
malaria, anaemia . A preterm birth is any birth
prior to 37 weeks gestation (40 is normal). The
earlier the birth the higher the probability of
being born less than 2500 gms.
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Birth Asphyxia and Birth Trauma
Birth asphyxia is caused by a lack of oxygen to
the fetus for long enough to cause permanent
damage or death. Birth trauma is due to damage
to the fetus during delivery. Birth asphyxia
and birth trauma are strongly influenced by
obstetric care during labour and delivery.
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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services
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Contraception and Family Planning
Fertility regulation through the provision of
effective contraceptive technologies is an
important intervention to reduce maternal
mortality. Lifetime risk of maternal death is a
function of the risk per birth and the total
number of births. Countries with very high MMR
also have high TFRs so that fertility reduction
in these communities would have a significant
impact on global maternal deaths. Effective
contraception will reduce the abortion rate and
maternal deaths associated with unsafe
abortion. Reductions in the TFR will most likely
lead to reductions in child mortality because of
increased birth spacing.
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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services
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Antenatal Care
Antenatal care came into widespread use in the UK
in the 1930s as a means to identify women at risk
of pre-eclampsia and eclampsia. In developing
countries, antenatal care was promoted and has
become one of the most widespread health
interventions. The utility of risk assessment to
reduce maternal mortality, the original basis for
antenatal care has been questioned. Antenatal
contacts can, however, be the basis for
delivering a number of proven technologies. Even
though, this potential is not yet used in many
settings.
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Antenatal Care Technologies

• Intermittent prophylaxis for malaria
• Nevirapine to reduce MTCT of HIV new drugs
  being tested.
• Treatment of STDs
• Anaemia treatment
• Pre-eclampsia screening through blood pressure
  measurement and detection of protein in a urine
  test
• Education to identify dangerous complications
  during labour
• Education to use insecticide treated nets

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Has the Investment in Antenatal Care Been Wasted?
Enormous energy and resources have been invested
in low-income countries to convince pregnant
women to seek antenatal care and to make
antenatal clinics physically, financially and
culturally accessible. Antenatal care as
delivered in most poor countries probably has a
very limited effect on perinatal mortality and
little direct effect on maternal mortality. At
present, the major effect may be to increase the
probability that a womens birth is attended by a
skilled personnel. The causality of this
relationship, however, has not been established.

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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services
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Managing Labour and Delivery

• Reducing maternal mortality requires
• Skilled birth attendants
• Rapid referral and transport to emergency
  obstetric services when needed
• Well-equipped and staffed health facility to
  undertake caesarian section, etc.

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Roles of the Skilled Birth Attendant

• Ensures a clean, safe, normal delivery
• Recognizes and responds to complications by
  managing minor ones (removal of placenta, repair
  of vaginal tear, oxytocin for haemorrhage) and
  refers promptly major ones
• Provides pain relief
• Monitors maternal and fetal well-being throughout
• Ensures newborn breathes on its own and is
  protected from hypothermia and cord infection
• Ensures initiation of early breastfeeding

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Essential Emergency Obstetrical Care

• Capacity to carry out surgery caesarian
  section, treatment of sepsis, removal of ectopic
  pregnancy
• Intravenous oxytocin
• Anaesthesia
• Medical management of shock, sepsis, anaemia and
  hypertensive disorders of pregnancy
• Replacement of blood
• Manual procedures e.g. vacuum extractions
• .

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Skilled Birth Attendance
Household survey data provide information on
extent of skilled birth attendance, but not on
the quality of the care. No real data on
emergency obstetrical services. Skilled
attendants is taken as a proxy for the package of
services. But this indicator is probably much
higher than percentage of women covered by the
package of skilled birth attendance and emergency
obstetrical care. Very complex intervention
requiring physical, financial and cultural access
to quality health care network.
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Definitions of Sexual and Reproductive
Health Reproductive Health as Political
Movement Burden of Reproductive Health
Problems Contraception and Fertility
Control Antenatal Care Labour, Delivery and the
Post-Partum Period Abortion and Post-Abortion
Services
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Abortion and Post Abortion Care
Approximately 70,000 women die each year from
complications of abortion. Access to safe
abortion would likely decrease maternal mortality
from abortion. Post abortion care is also
important and is composed of emergency services
for complications of abortion, and post abortion
family planning counselling. Because abortion is
illegal or unpopular in many countries, the
research on abortion and interventions to reduce
its impact has been limited.