Global Health Challenges Social Analysis 76: Lecture 11

Harvard University Initiative for Global Health

Global Health ChallengesSocial Analysis 76: Lecture 11


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


1)1) Consequences of sex in adults – STDs, maternal causes, HIV, Consequences of sex in adults – STDs, maternal causes, HIV, Hepatitis B, Human Papilloma VirusHepatitis B, Human Papilloma Virus

2)2) Consequences of sex in adults and children – adding Consequences of sex in adults and children – adding congenital anomalies, birth asphyxia, birth trauma, and other congenital anomalies, birth asphyxia, birth trauma, and other conditions arising during the perinatal period. conditions arising during the perinatal period.

3)3) Conditions of the reproductive organ systems – STDS, Conditions of the reproductive organ systems – STDS, maternal causes, reproductive cancersmaternal causes, reproductive cancers

4)4) Conditions managed through reproductive health services – all Conditions managed through reproductive health services – all maternal and child causes.maternal and child causes.

5)5) Conditions arising in the reproductive age-groups (15-44). Conditions arising in the reproductive age-groups (15-44).

6)6) Health problems predominantly affecting reproductive age-Health problems predominantly affecting reproductive age-groups. groups.

Sexual and Reproductive Health Definitions


Global Burden of Disease 2002

HIV/AIDS

6%

Breast cancer

0%

Cervix uteri cancer

0%

Ovary cancer

0%

OTHER GROUP I

26%Other Group II

44%

Injuries

12%

Congenital

abnormalities2%

Corpus uteri

cancer0%

Perinatal conditions

7%Maternal conditions

2%

STDs

1%

Liver cancer

0%






Antenatal Care




Early 1960s, growing concern in high-income countries Early 1960s, growing concern in high-income countries that population growth in developing countries that population growth in developing countries would lead to a total world population beyond the would lead to a total world population beyond the earth’s environmental carrying capacity. earth’s environmental carrying capacity.

During 1970s and 1980s, major investments by US and During 1970s and 1980s, major investments by US and other Western donors in the development of other Western donors in the development of contraceptive technologies and the delivery of contraceptive technologies and the delivery of contraceptive services to developing countries. contraceptive services to developing countries.

Spectacular fertility declines in many countries beyond Spectacular fertility declines in many countries beyond what was expected due to income growth or what was expected due to income growth or increases in educational attainment. increases in educational attainment.

Population Explosion and Control


At the decennial International Population and At the decennial International Population and Development Conference in Cairo in 1994, the Development Conference in Cairo in 1994, the population community favoured a major policy shift population community favoured a major policy shift from a focus on population control to the delivery of from a focus on population control to the delivery of reproductive health services including options for reproductive health services including options for fertility regulation. fertility regulation.

One interpretation is that the population community One interpretation is that the population community was ‘captured’ by the health community. was ‘captured’ by the health community.

Cairo Conference 1994


Eight target areas were identified:Eight target areas were identified:

1)1) Unplanned pregnancy and unsafe abortionUnplanned pregnancy and unsafe abortion

2)2) Maternal mortality and morbidityMaternal mortality and morbidity

3)3) Reproductive tract infections including STDsReproductive tract infections including STDs

4)4) HIV/AIDSHIV/AIDS

5)5) Reproductive tract cancersReproductive tract cancers

6)6) Female genital mutilation and gender based Female genital mutilation and gender based violenceviolence

7)7) InfertilityInfertility

8)8) Menopause Menopause

Cairo Agenda


Huge decline in policy attention in population control – Huge decline in policy attention in population control – driven by declines in TFR and Cairo agenda changedriven by declines in TFR and Cairo agenda change

Reproductive health as an international political agenda Reproductive health as an international political agenda has lost some of its prominence because of US and has lost some of its prominence because of US and conservative states (Iran, Vatican) antagonism to conservative states (Iran, Vatican) antagonism to components of the agenda. components of the agenda.

Reproductive health was not included as a specific goal Reproductive health was not included as a specific goal in the Millennium Development Goals although in the Millennium Development Goals although reducing maternal mortality was one of eight goals. reducing maternal mortality was one of eight goals.

2004 many reflections and analyses in the literature.2004 many reflections and analyses in the literature.

10 Years After Cairo






Antenatal Care



Challenges and Controversies


Three measures of maternal mortality:Three measures of maternal mortality:

1)1) Maternal mortality ratio – number of maternal Maternal mortality ratio – number of maternal deaths per 100,000 live birthsdeaths per 100,000 live births

2)2) Maternal mortality rate – number of maternal deaths Maternal mortality rate – number of maternal deaths per 100,000 women aged 15-49per 100,000 women aged 15-49

3)3) Lifetime risk of maternal death – cumulative Lifetime risk of maternal death – cumulative probability of death from a maternal cause between probability of death from a maternal cause between 15 and 50. 15 and 50.

Maternal Mortality


1.1. Haemorrhage – prepartum, intrapartum and Haemorrhage – prepartum, intrapartum and postpartumpostpartum

2.2. Sepsis – systemic infectionSepsis – systemic infection

3.3. Hypertensive disorders or pregnancy – pre-Hypertensive disorders or pregnancy – pre-eclampsia, eclampsiaeclampsia, eclampsia

4.4. Obstructed labourObstructed labour

5.5. Unsafe abortion Unsafe abortion

6.6. Other Other

Maternal Causes


Maternal Mortality by Cause 1990

Sepsis15%

Obstructed Labour

8%

Abortion 14%

Other26%

Hemorrhage25%

Hypertensive Disorders

12%

DALYs by Maternal Cause 1990

Hemorrhage12%

Sepsis18%

Hypertensive Disorders

5%

Obstructed Labour22%

Abortion 17%

Other26%


Approximately two-thirds of perinatal conditions are due Approximately two-thirds of perinatal conditions are due to low birth weight, defined as a birth weight less to low birth weight, defined as a birth weight less than 2500 grams.than 2500 grams.

Two causes of low birth weight: small for gestational Two causes of low birth weight: small for gestational age and preterm. age and preterm.

In developing countries, largest component (60%) of In developing countries, largest component (60%) of low birth weight is small for gestational age. Risk low birth weight is small for gestational age. Risk factors include maternal nutritional status, diabetes, factors include maternal nutritional status, diabetes, hypertension, malaria, anaemia ….hypertension, malaria, anaemia ….

A preterm birth is any birth prior to 37 weeks gestation A preterm birth is any birth prior to 37 weeks gestation (40 is normal). The earlier the birth the higher the (40 is normal). The earlier the birth the higher the probability of being born less than 2500 gms.probability of being born less than 2500 gms.

Low Birth Weight


Birth asphyxia is caused by a lack of oxygen to the Birth asphyxia is caused by a lack of oxygen to the fetus for long enough to cause permanent damage fetus for long enough to cause permanent damage or death. or death.

Birth trauma is due to damage to the fetus during Birth trauma is due to damage to the fetus during delivery. delivery.

Birth asphyxia and birth trauma are strongly influenced Birth asphyxia and birth trauma are strongly influenced by obstetric care during labour and delivery. by obstetric care during labour and delivery.

Birth Asphyxia and Birth Trauma






Antenatal Care




Fertility regulation through the provision of effective Fertility regulation through the provision of effective contraceptive technologies is an important contraceptive technologies is an important intervention to reduce maternal mortality.intervention to reduce maternal mortality.

Lifetime risk of maternal death is a function of the risk Lifetime risk of maternal death is a function of the risk per birth and the total number of births. per birth and the total number of births.

Countries with very high MMR also have high TFRs so Countries with very high MMR also have high TFRs so that fertility reduction in these communities would that fertility reduction in these communities would have a significant impact on global maternal deaths.have a significant impact on global maternal deaths.

Effective contraception will reduce the abortion rate and Effective contraception will reduce the abortion rate and maternal deaths associated with unsafe abortion.maternal deaths associated with unsafe abortion.

Reductions in the TFR will most likely lead to Reductions in the TFR will most likely lead to reductions in child mortality because of increased reductions in child mortality because of increased birth spacing. birth spacing.

Contraception and Family Planning






Antenatal Care




Antenatal care came into widespread use in the UK in Antenatal care came into widespread use in the UK in the 1930s as a means to identify women at risk of the 1930s as a means to identify women at risk of pre-eclampsia and eclampsia. pre-eclampsia and eclampsia.

In developing countries, antenatal care was promoted In developing countries, antenatal care was promoted and has become one of the most widespread health and has become one of the most widespread health interventions.interventions.

The utility of risk assessment to reduce maternal The utility of risk assessment to reduce maternal mortality, the original basis for antenatal care has mortality, the original basis for antenatal care has been questioned. been questioned.

Antenatal contacts can, however, be the basis for Antenatal contacts can, however, be the basis for delivering a number of proven technologies. Even delivering a number of proven technologies. Even though, this potential is not yet used in many though, this potential is not yet used in many settings. settings.

Antenatal Care


1.1. Intermittent prophylaxis for malariaIntermittent prophylaxis for malaria

2.2. Nevirapine to reduce MTCT of HIV – new drugs Nevirapine to reduce MTCT of HIV – new drugs being tested.being tested.

3.3. Treatment of STDsTreatment of STDs

4.4. Anaemia treatmentAnaemia treatment

5.5. Pre-eclampsia screening through blood pressure Pre-eclampsia screening through blood pressure measurement and detection of protein in a urine testmeasurement and detection of protein in a urine test

6.6. Education to identify dangerous complications Education to identify dangerous complications during labourduring labour

7.7. Education to use insecticide treated netsEducation to use insecticide treated nets

Antenatal Care Technologies


Enormous energy and resources have been invested in Enormous energy and resources have been invested in low-income countries to convince pregnant women low-income countries to convince pregnant women to seek antenatal care and to make antenatal clinics to seek antenatal care and to make antenatal clinics physically, financially and culturally accessible. physically, financially and culturally accessible.

Antenatal care as delivered in most poor countries Antenatal care as delivered in most poor countries probably has a very limited effect on perinatal probably has a very limited effect on perinatal mortality and little direct effect on maternal mortality. mortality and little direct effect on maternal mortality.

At present, the major effect may be to increase the At present, the major effect may be to increase the probability that a women’s birth is attended by a probability that a women’s birth is attended by a skilled personnel. The causality of this relationship, skilled personnel. The causality of this relationship, however, has not been established. however, has not been established.

Has the Investment in Antenatal Care Been Wasted?






Antenatal Care




Reducing maternal mortality requires:Reducing maternal mortality requires:

1)1) Skilled birth attendantsSkilled birth attendants

2)2) Rapid referral and transport to emergency obstetric Rapid referral and transport to emergency obstetric services when neededservices when needed

3)3) Well-equipped and staffed health facility to Well-equipped and staffed health facility to undertake caesarian section, etc. undertake caesarian section, etc.

Managing Labour and Delivery


1)1) Ensures a clean, safe, normal deliveryEnsures a clean, safe, normal delivery

2)2) Recognizes and responds to complications by Recognizes and responds to complications by managing minor ones (removal of placenta, repair managing minor ones (removal of placenta, repair of vaginal tear, oxytocin for haemorrhage) and of vaginal tear, oxytocin for haemorrhage) and refers promptly major onesrefers promptly major ones

3)3) Provides pain reliefProvides pain relief

4)4) Monitors maternal and fetal well-being throughoutMonitors maternal and fetal well-being throughout

5)5) Ensures newborn breathes on its own and is Ensures newborn breathes on its own and is protected from hypothermia and cord infectionprotected from hypothermia and cord infection

6)6) Ensures initiation of early breastfeedingEnsures initiation of early breastfeeding

Roles of the Skilled Birth Attendant


1)1) Capacity to carry out surgery – caesarian section, Capacity to carry out surgery – caesarian section, treatment of sepsis, removal of ectopic pregnancytreatment of sepsis, removal of ectopic pregnancy

2)2) Intravenous oxytocinIntravenous oxytocin

3)3) AnaesthesiaAnaesthesia

4)4) Medical management of shock, sepsis, anaemia Medical management of shock, sepsis, anaemia and hypertensive disorders of pregnancyand hypertensive disorders of pregnancy

5)5) Replacement of bloodReplacement of blood

6)6) Manual procedures e.g. vacuum extractions Manual procedures e.g. vacuum extractions

7)7) …………..

Essential Emergency Obstetrical Care


Household survey data provide information on extent of Household survey data provide information on extent of skilled birth attendance, but not on the quality of the skilled birth attendance, but not on the quality of the care. care.

No real data on emergency obstetrical services. Skilled No real data on emergency obstetrical services. Skilled attendants is taken as a proxy for the package of attendants is taken as a proxy for the package of services. But this indicator is probably much higher services. But this indicator is probably much higher than percentage of women covered by the package than percentage of women covered by the package of skilled birth attendance and emergency of skilled birth attendance and emergency obstetrical care. obstetrical care.

Very complex intervention requiring physical, financial Very complex intervention requiring physical, financial and cultural access to quality health care network.and cultural access to quality health care network.

Skilled Birth Attendance


Benin

Benin

Burkina Faso

Burkina FasoCote d'Ivoire

Cote d'Ivoire

GhanaGhana Ghana

Kenya Kenya

Madagascar

Madagascar

Malawi Malawi

Mali

Mali

NigerNiger

SenegalSenegal

United Republic of Tanzania



Zambia Zambia

Zimbabwe ZimbabweZimbabwe

0.2

.4.6

.81

Pro

po

rtio

n o

f bir

ths

atte

nd

ed

by

skill

ed p

ers

on

ne

l

1985 1990 1995 2000Year

Poorest QuintileTrends in Skilled Birth Attendance






Antenatal Care




Approximately 70,000 women die each year from Approximately 70,000 women die each year from complications of abortion.complications of abortion.

Access to safe abortion would likely decrease maternal Access to safe abortion would likely decrease maternal mortality from abortion.mortality from abortion.

Post abortion care is also important and is composed of Post abortion care is also important and is composed of emergency services for complications of abortion, emergency services for complications of abortion, and post abortion family planning counselling.and post abortion family planning counselling.

Because abortion is illegal or unpopular in many Because abortion is illegal or unpopular in many countries, the research on abortion and countries, the research on abortion and interventions to reduce its impact has been limited. interventions to reduce its impact has been limited.

Abortion and Post Abortion Care

Global Health Challenges Social Analysis 76: Lecture 11

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