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A call for a more balanced approach to reproductive health in resource poor countries. Nathalie Dhont


Reproductive health according to WHO

‌ health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity‌ ‌ reproductive health addresses the reproductive processes, functions and system at all stages of life. Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.


Neonatal care Pediatric care

Peri- and post partum care

Sexual education

Antenatal care

Fertility care


• •

UNFPA Improving Reproductive Health

Everyone has the right to enjoy reproductive health, which is a basis for having healthy children, intimate relationships and happy families. Reproductive health encompasses key areas of the UNFPA vision – that every child is wanted, every birth is safe, every young person is free of HIV and every girl and woman is treated with dignity and respect. Reproductive health problems remain the leading cause of ill health and death for women of childbearing age worldwide. Impoverished women, especially those living in developing countries, suffer disproportionately from unintended pregnancies, maternal death and disability, sexually transmitted infections including HIV, gender-based violence and other problems related to their reproductive system and sexual behaviour. Because young people often face barriers in trying to get the information or care they need, adolescent reproductive health is another important focus of UNFPA programming. And all programming relies on the availability of essential supplies. The critical importance of reproductive health to development has been acknowledged at the highest level. At the 2005 World Summit, world leaders added universal access to reproductive health as a target in Millennium Development Goals framework. UNFPA is fully committed to mobilizing support and scaling up efforts to make reproductive health for all a reality by 2015.


ICRH

Approach to sexual and reproductive health • family planning and contraception; • safe motherhood, including aspects related to unwanted pregnancies; • sexually transmitted infections, including HIV/AIDS and cervical cancer; • discouragement of harmful practices such as female genital mutilation and early marriages; • sexual and gender-based violence, prevention and response.


Neonatal care Pediatric care

Peri- and post partum care

Sexual education

Antenatal care

Fertility Fertility Fertility care restriction restriction


‌Implicit in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.


United nations Millenium development goals (189 countries) 1

End poverty and hunger

2

Universal education

3

Gender equality

4

Child health

5

Maternal health

6

Combat HIV/AIDS

7

Environmental sustainability

8

Global partnerships

1. 2. • • • •

Reduce by three quarters the maternal mortality ratio Achieve universal access to reproductive health Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage Unmet need for family planning


acceptable arguments Infertility not very prevalent in developing countries


Large scale • overall 10%, similar with resource-rich countries (J Boivin et al, Hum Reprod 2007; 22(6):1506-1512)

• but wide variation, in some countries up to 30% (infertility belt) and secondary infertility higher than primary infertility (Ericksen K, Brunette T in Soc. Sci. Med. Vol42, n2 , pp 209-220 ,1996 ;Larsen U in Int J Epidemiology 2000;29:285-291)

• probably declining since 1970 •Cameroon- Gabon- Congo-Central African Republic


Infertility is not a serious problem for people in developing countries


Infertility causes enormous suffering Value of children in Africa •Marital stability •Social status •Continuity of family line •Social security Dyer SJ in JPsychObsGyn, 2007; in HumReprod,2004; inHumReprod,2002 (SouthAfrica) Richards S in AfrJReprodHealth,2002(Cameroon) Gerrits T in PatientEducCouns,1997(Mozambique) Hollos M in AfrJReprodHealth,2003 (Nigeria) Sundby in PatientEducCounsel, 1997 (Gambia) Van Balen F, Gerrits G in Hum.Reprod. 2001, 16:215-219 Araoye MO in Wes Afr J Med 2003 Jun;22(2):190-6


“Individual problem, not a public health problem, not a problem of the nation…”


ICPD — International Conference on Population and Development , 1994 Cairo ICPD was a milestone in the history of population and development, as well as in the history of women's rights. At the conference, the world agreed that population is not about numbers, but about people. Implicit in this rights-based approach is the idea that every person counts. The conference also made it clear that empowerment of women is not simply an end in itself, but also a step towards eradicating poverty and stabilizing population growth. Reproductive health and rights are cornerstones of women's empowerment.


Papreen Nahar, presented in Genk 2011


the principle of Ubuntu

I am what I am because of what we are’


The double stigma of infertility • a cultural context of great value of children, childbearing and motherhood: ‘Barren among plenty’ : infertile couple excluded from society • A nation which prioritizes the control of family sizes: infertile couple excluded from public health agenda


Study on risk factors and determinants of infertility • Study was conducted in University hospital in Kigali from November 2007 until May 2009. • Cases were women with history of 1 year infertility • An unmatched control group of fertile women (defined as women who recently delivered) were sampled from the same geographical area. • Data were collected on demographics, sexual behavior and STIs in the past using a structured questionnaire during face to face interviews • blood was drawn for HIV testing, HSV serology and syphilis serology.


Fertile relation-ship n=283 n (%)

Infertile relation-ship n=312 n (%)

AOR*

Lifetime sex history Lifetime sex partners>2

45 (16)

140 (45)

Union dissolutions

31 (11)

61 (20)

Ever transactional sex

16 (6)

26 (8)

Age first intercourse < 15

22 (8)

32 (10)

Sexual violence

28 (10)

79 (25)

Never used condoms

94 (33)

161 (52)

6.01 (3.87-9.31) 1.62 (0.97-2.73) 2.75 (1.36-5.57) 1.81 (0.99-3.31) 3.02 (1.85-4.91) 1.67 (0.64-1.41)

Recent sex history Multiple partners last year

2 (1)

9 (3)

Thinks partner unfaithful

18 (6)

67 (21)

5.96 (1.22-29.02) 2.20 (1.64-2.93)


Cases N=177 n (%)

Controls N=219 n (%)

Age adjusted OR

First pregnancy before age 21 years

97 (55)

92 (42)

2.56 (1.63-4.02)

Unwanted pregnancy

49 (28)

11 (5)

11.51 (5.47-24.20)

Pregnancy with another partner

105 (59)

48 (22)

5.68 (3.56-9.08)

No prenatal care in last pregnancy1

20 (15)

7 (4)

4.68 (1.81-12.12)

Adverse pregnancy outcome2

57 (32)

44 (20)

1.89 (1.17-3.04)

Stillbirth

32 (18)

6 (3)

7.52 (2.97-19.01)

3 (2)

0 (0)

1.33 (0.73-2.39)

24 (13)

3 (1)

11.49 (3.31-39.89)

Positive HIV serology

74 (42)

35 (16)

4.10 (2.50-6.72)

Positive HSV-2 serology

121 (70)

99 (45)

2.56 (1.65-3.96)

Positive Chlamydia serology

31 (18)

33 (15)

1.58 (0.89-2.80)

Old treated syphilis

16 (9)

8 (4)

2.85 (1.13-7.18)

Variable

Obstetrical and reproductive history

Unsafe abortion Postpartum infection Reproductive tract infections


Poverty, low education, gender inequality, high value of children, limited heath care

• Transactional sex • Concurrent partners • Multiple unions • No condom use • Early age at first sex • Gender based violence

Bad Badsexual sexual health, health, obstetric obstetricand and neonatal neonatalcare care STIs/HIV STIs/HIVand and unintended unintended pregnancies pregnancies (unsafe (unsafe abortions) abortions)

INFERTILITY INFERTILITYAND AND CHILDLESSNESS CHILDLESSNESS


â&#x20AC;&#x153;The fact that (secondary) infertile women are more likely to be HIV infected and to report lifetime highrisk sexual behaviour than fertile women suggests that this group of women may enter a vicious circle of unsafe sex, beginning from the start of sexual activity, leading to a first pregnancy (in many cases unplanned and ending in complicated childbirth), STIs and HIV infection, all of which can impair their fertility. Thus, the different aspects of reproductive ill health go hand in hand indicating a need for a more holistic approach towards reproductive health services in SSA. â&#x20AC;&#x153;


Some additional arguments • A more couple friendly family planning program • HIV prevention • Safe sex messages more efficient


Current model of reproductive healthcare: vertical, infertility excluded


Holistic model of reproductive healthcare: horizontal and infertility included


Why including infertility care… • To help 185 million couples • From a reproductive rights approach • To make reproductive health care more efficient


Thank you all for listening!


Unacceptable arguments • Overpopulation argument Because neighbor has too many… • Limited resources Matter of political will, look at AIDS and ARV’s • No treatment but prevention No mention of infertility in safe sex campaign…



A Call for a more holistic approach to reproductive health