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- Reproductive Health, Gender and Human Rights: A Dialogue!
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Apply for a prize For students For trainees Travel grants and bursaries About prizes and awards. Watch and listen Podcasts Videos. Services Sponsorship and exhibiting Venue hire. The course covers the most critical topics in this field from diverse perspectives, i. The topics include the role of the global community in shaping the sexual and reproductive health agenda, maternal health quality of care and critical interventions, unsafe abortion, contraception, cancer and reproductive health and integration of reproductive health care. Gender, social inequalities, and rights will be underpinning dimensions along the entire course.
Students are introduced to the core sexual and reproductive health literature and learn about the outstanding debates, acute knowledge gaps, evidence-based interventions, current challenges, and the most promising public health approaches to overcome them. Interventions in China, Ghana, India, Kenya, Nicaragua, Tanzania, Uganda, and Zimbabwe have shown that providing one or more of the components of adolescent-friendly contraceptive services can increase use of contraceptives or condoms Decker and Montagu ; Kanesathasan and others ; Karim and others ; Kim and others ; Lou and others ; Meuwissen, Gorter, and Knottnerus ; Williams and others Youth centers, however, have not been found to be an effective and efficient programming strategy for reaching youth Zuurmond, Geary, and Ross Expand access to and promotion of the use of condoms and other contraceptives.
Ensuring access to and regular use of condoms and other contraceptives is an essential element in programs to protect youth from unintended pregnancies and STIs. The use of condoms to guard against STIs can provide the added benefit of safeguarding fertility Brady Promoting condoms for pregnancy prevention, as well as for prevention of HIV and other STIs, could increase condom use for safe sex among young people Agha An analysis of survey data from 18 Sub-Saharan African countries finds that use of condoms for pregnancy prevention rose significantly in 13 of 18 countries between and Condom use among young Sub-Saharan African women increased by an average annual rate of 1.
Evidence suggests that if condom use is established during adolescence, it is more likely to be sustained in the long term Schutt-Aine and Maddaleno A new study is underway to study the effects of fertility awareness on contraceptive use IRH, n. Implement programs for out-of-school and married adolescents. Most programming for adolescents is school- or health facility—based, yet millions of children and adolescents are not in school. Mass media approaches and CBP show promise in reaching out-of-school adolescents, although programming for this group is challenging Bhuiya and others Programs to improve life skills and build resilience to risk factors among adolescents have shown promising results Askew and others ; Erulkar and others ; Kanesathasan and others ; Kim and others ; Mathur, Mehta, and Malhotra ; Meekers, Stallworthy, and Harris These programs, which focus on building protective factors to promote success rather than eliminating factors associated with failure, have included a mix of community awareness and engagement of community leaders; assistance to link adolescents with significant adults in their lives, most notably parents; provision of safe spaces for adolescents; and provision of information, services, and the building of skills.
Cuidate, a sexual-risk-reduction program in Mexico, provides a six-hour training program for parents and adolescents. After four years, the adolescent program participants were more likely to be older at first sexual activity and to use a condom or other contraceptive at first sexual activity, compared with the control group Villarruel and others Although the need for abortion can be reduced if the need for contraceptive options is better addressed, the need for safe abortion care will remain.
Contraceptive methods do fail; women often become pregnant in circumstances in which the use of contraception may not be possible or where sex is nonconsensual.
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Medical or other circumstances for the woman could change even after she becomes pregnant. Abortion in early pregnancy less than nine weeks performed with appropriate techniques by trained personnel is one of the safest medical procedures, with a case fatality rate of 0. Complications increase with increasing gestation, but the termination of pregnancy remains a safe procedure. The WHO recognizes vacuum aspiration manual and electric up to 12—14 weeks of gestation, and dilation and evacuation beyond that stage, as safe and appropriate surgical procedures.
Medical abortion using the sequential combination of mifepristone, followed by misoprostol, is recommended as a safe and effective method that can be used at any stage of pregnancy, although doses and specific protocols change as gestation advances. Vacuum aspiration can be provided on an outpatient basis at the primary care level; medical abortion up to nine weeks is a process rather than a procedure and can be managed as an outpatient primary care service, with some of the medications taken by women at home WHO Although simple, safe, and effective medical interventions already exist, appropriate technology is of little benefit if it is not used by providers and is not accessible to women.
Therein lies the challenge. Legal restrictions on the circumstances under which abortions are permitted or who can provide them; critical health workforce shortages, particularly in South Asia and Sub-Saharan Africa; lack of training opportunities for providers; conscientious objection to care provision on the part of some providers; and the social, cultural, and political stigma around abortion all make it difficult to ensure access to safe abortion care.
Despite the availability of vacuum aspiration for more than 40 years, the use of sharp curettage dilation and curettage is still common in many countries.
Sexual and reproductive rights: A global perspective
The WHO no longer recommends dilation and curettage because it has more complications, often needs general anesthesia, and has higher costs for women and health facilities WHO Services to the full extent of the law. Although laws vary, all but six countries allow legal abortion in some circumstances, most often to save the life of the woman and often when pregnancy is the result of rape or incest UN Population Division a. Whatever the legal context, the treatment of women with complications is legal, and evacuation in case of incomplete abortion is a signal function of basic emergency obstetric care.
Interpreting and implementing laws to their full extent and keeping the health of women center stage can make safer care more accessible. Expanding the pool of providers. A systematic review of the evidence shows that both vacuum aspiration and medical abortion can be safely provided by non-physician providers Renner, Brahmi, and Kapp Many countries allow clinical associates, midwives, or nurses to treat incomplete abortion using manual vacuum aspiration; several, including Vietnam, allow them to provide induced abortion as well.
Bangladesh has had a mature program with auxiliary workers providing menstrual regulation for more than 40 years Johnston and others Because medical abortion is a relatively newer technology, fewer countries have yet moved to decentralize care; it is well-suited to a wider provider base since it does not need surgical skills. Ethiopia and Ghana both allow midwives to provide medical abortions, and Nepal has incrementally progressed to allowing midwives, then nurses, and more recently, auxiliary nurses working at lower-level facilities to provide medical abortions, demonstrating the feasibility even in low-resource settings.
In many contexts, a pharmacy is the first and sometimes only health care contact for a woman with an unintended pregnancy. Although results have not always been successful, interventions to provide pharmacy workers with accurate information, minimize harm, or develop referral linkages with other authorized providers have potential and need to be further explored Sneeringer and others Similarly, community health workers can play a role in assessing eligibility, making appropriate referrals, and helping women determine the need for follow-up care.
Where mifepristone is not available. If mifepristone is not available, misoprostol, an inexpensive anti-ulcer medicine with other obstetric and gynecological uses, is usually more readily accessible and can be used alone to terminate a pregnancy. The failure rate is higher than when used in combination with mifepristone, but it is still safe and effective, and is a WHO-recommended option WHO Important gains in reducing the morbidity and mortality from unsafe abortions have been made, especially in Latin America and the Caribbean, with the use of this strategy.
The use of telemedicine to provide medical abortions can help bring needed care to women who do not have physical access Gomperts and others ; Grindlay, Lane, and Grossman ; Grossman and others Decreasing the need for clinic visits through approaches that allow telephone follow-up or self-assessment of the abortion process using semi-quantitative pregnancy tests Lynd and others is another promising innovation.
The risk-reduction model pioneered in Uruguay combines provision of information and post-abortion care; this approach can be legally implemented even in countries with restrictive legal environments Fiol and others Information and attitudes. Even where abortion is legal, women are often unaware of how and where to access it Adinma and others ; Banerjee and others ; Thapa, Sharma, and Khatiwada Approaches to empowering women with knowledge using interpersonal communication, drama, theater, radio, wall signage, and mass media communication have all had some success; understanding the local context and appropriately tailoring the approach is critical Banerjee and others ; Bingham and others Telephone help lines can provide confidential sources of information and support.
Social networking and Internet-based information are becoming increasingly important in providing accurate information; however, empowering women to be able to detect misinformation and avoid dangers, like the sale of spurious medical abortion agents, is also needed. Addressing the stigma and taboos around sexuality, unintended pregnancies, and abortion is important, as is providing women with the information and skills to negotiate traditional gender roles and inequities. Providers need medically accurate information and the skills to be able to clarify internal values and provide care to women in a nonjudgmental way.
Postabortion contraception. Although the evidence on its overall impact on maternal mortality has not been well studied, ensuring effective and seamless linkages among abortion care, contraceptive information, voluntary counseling, and onsite availability of contraception is an important strategy for increasing the use of post-abortion contraception and helping women prevent subsequent unintended pregnancies Tripney, Kwan, and Bird However, ensuring that contraceptive acceptance does not become coercive or a precondition to getting abortion care is also needed.
A multifaceted approach is needed. An excellent example is seen in Nepal, where legal reform followed by proactive efforts to scale up services has yielded rich dividends and already shows some evidence of a decline in serious morbidity from unsafe abortion Henderson and others ; Samandari and others Safe abortion has been shown to be cost-effective see DCP3 , volume 1, Essential Surgery , chapter 18 [Prinja and others ].
Primary prevention of violence is critically important, but it is also necessary to provide care and support for the many women who already face violence. Early identification and response can play an important role in secondary prevention by mitigating the consequences of violence and reducing the risk of further violent episodes. Early identification and response can also contribute to primary prevention by identifying and supporting the children of women who suffer domestic violence. Evidence suggests that early intervention is likely to have a positive impact on later risk behaviors and health problems among children and adolescents.
It can also contribute to reducing the social and economic costs of such violence. Although violence against women has been accepted as a critical public health and clinical care issue, the health care policies of many countries still do not address it. The critical role that the health system and health care providers can play in identification, assessment, treatment, crisis intervention, documentation, referral, and follow-up is poorly understood or poorly accepted within national health programs and policies WHO ; WHO c.
Women who have been subjected to violence often seek health care for their injuries, even if they may not disclose the associated abuse or violence, and a health care provider is likely to be the first professional contact for survivors of intimate partner violence or sexual assault. Women also identify health care providers as the professionals they would most trust with the disclosure of abuse Feder and others Reproductive health care providers are particularly well positioned given that most women will at some point consult them for contraception, antenatal care, and delivery.
The WHO clinical and policy guidelines WHO summarize the evidence for clinical interventions for intimate partner violence and for sexual violence against women. They also review the evidence for service delivery and training on these issues for health care providers and make evidence-based recommendations to improve the response of the health sector to violence against women.
Health professionals can provide assistance to women suffering from violence by facilitating disclosure, offering support and referral, gathering forensic evidence— particularly in cases of sexual violence—and providing the appropriate medical services and follow-up care. Health care providers who come into contact with women facing intimate partner violence need to be able to recognize the signs and respond appropriately and safely.
Women exposed to violence require comprehensive, gender-sensitive health care services that address the physical and mental health consequences of their experience and aid their recovery. Women may also require crisis intervention services to prevent further harm. Treating cases of rape includes providing emergency contraception and prophylaxis for HIV and other STIs; psychological first-line support; and access to safe abortion and longer-term mental health care support, if needed.
In addition to providing immediate medical services, the health sector is a potentially crucial gateway to providing assistance through referral to specific services for violence against women—or other aid that women may require at a later date, such as social welfare and legal aid. In all circumstances, all health care providers should be trained to provide a minimum first-line supportive response WHO , b.
The WHO recommendations are addressed to health care providers because they are in a unique position to address the health and psychosocial needs of women who live with or who have experienced violence. They also seek to inform health policy makers or program managers in charge of planning and implementing health care services and those designing curricula. The health sector can also play an advocacy role by supporting research to document the impact and extent of the problem, raise awareness, and establish links in the multisectoral response that is needed to address this serious health risk for women.
Sexual and Reproductive Health and Population Studies
Significant progress in improving reproductive health has been made in some areas. Family planning has expanded worldwide through new approaches and new methods. A renewed commitment to family planning among donors and national governments has stimulated wider coverage of services accompanied by greater emphasis on quality and human rights. A new focus on adolescent sexual health has spurred interest in better ways to reach adolescents with effective messages and services.
New approaches to reducing gender-based violence have been tested and the lessons learned have been distilled in clinical and policy guidelines. However, much remains to be done. In spite of the advances in family planning, in 35 countries fewer than 30 percent of women of reproductive age use modern contraception. Choice of methods is still limited in many countries, even some with high levels of contraceptive prevalence, because of lack of access, provider biases, and other program factors.
Although good options for safe abortion exist, these services remain unavailable in many countries because of legal barriers, lack of training, and stigma. We have more information about how to reach adolescents with effective services and how to reduce gender-based violence.
Guidelines on Reproductive Health
The major challenge is how to more widely implement those programs that have been proven to be safe, effective, and affordable. This work is available under the Creative Commons Attribution 3. Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions:.
Attribution—Please cite the work as follows: Black, R. Laxminarayan, M. Temmerman, and N. Walker, editors. Reproductive, Maternal, Newborn, and Child Health. Disease Control Priorities , third edition, volume 2. Washington, DC: World Bank. Translations—If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by The World Bank and should not be considered an official World Bank translation.
The World Bank shall not be liable for any content or error in this translation. Adaptations—If you create an adaptation of this work, please add the following disclaimer along with the attribution: This is an adaptation of an original work by The World Bank. Views and opinions expressed in the adaptation are the sole responsibility of the author or authors of the adaptation and are not endorsed by The World Bank. Third-party content—The World Bank does not necessarily own each component of the content contained within the work.
The World Bank therefore does not warrant that the use of any third-party-owned individual component or part contained in the work will not infringe on the rights of those third parties. The risk of claims resulting from such infringement rests solely with you. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner.
Examples of components can include, but are not limited to, tables, figures, or images. Turn recording back on. National Center for Biotechnology Information , U. Search term. Introduction Health systems and individuals can take a number of actions to safeguard reproductive health. This chapter describes four areas of intervention: Family planning. Family Planning Rationales for Family Planning Programs Family planning has been a major development success over the past half century, with global fertility rates falling from more than six children per woman during her lifetime in the s to less than three children in the s.
Support for voluntary family planning has been based on several rationales, including the following Habumuremyi and Zenawi : Population and development, the so-called demographic rationale. Demographic Rationale The population and development rationale for family planning emerged in the s amid a concern that rates of rapid population growth would hinder economic growth in low- and middle-income countries LMICs and affect the ability of these countries to improve the well-being of their citizens. Maternal and Child Health Rationale The improved health of mothers and children has long been a rationale for the provision of family planning Seltzer Human Rights and Equity Rationale The right of couples and individuals to decide freely and responsibly on the number and spacing of their children was articulated at the International Conference on Human Rights UN Environment and Sustainable Development Rationale A resurgence of interest in global population dynamics is linked to growing attention to environmental issues, climate change, and concerns about food security Engelman ; Jiang and Hardee ; Martine and Schensul ; Moreland and Smith ; Royal Society Health Consequences of High Fertility High fertility affects the health of mothers and children in several ways.
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Contraceptive Methods A wide variety of contraceptive methods are available to women and men table 6. Table 6. Organization of Family Planning Programs Global Initiatives Family planning programming has been guided by global initiatives for decades, including through decennial population conferences in in Bucharest, in Mexico City, and in Cairo, as well as global frameworks, including the Millennium Development Goals MDGs. Services Delivery Family planning is delivered through a variety of programs and services. Adolescent Sexual and Reproductive Health The public health outcomes of adolescent pregnancy are profound.
Programming for Adolescents Providing adolescents with the means to attain high standards of health, in ways that ensure equality, nondiscrimination, privacy, and confidentiality, is an integral part of respecting and protecting globally accepted human rights Ringheim ; UNFPA Enabling Environment Provide legal protection. Information and Services Offer age-appropriate comprehensive sex education. Gurman and Underwood offer four lessons from their review: Ensure that the intervention is appropriate for the intended audience.
Design interventions that go beyond the individual level to include contextual factors, such as improving communication with caring adults, changing gender norms, and linking to services. Box 6. Building Resilience and Assets Programs to improve life skills and build resilience to risk factors among adolescents have shown promising results Askew and others ; Erulkar and others ; Kanesathasan and others ; Kim and others ; Mathur, Mehta, and Malhotra ; Meekers, Stallworthy, and Harris Safe and Simple Technologies The WHO recognizes vacuum aspiration manual and electric up to 12—14 weeks of gestation, and dilation and evacuation beyond that stage, as safe and appropriate surgical procedures.
Access to Technologies Although simple, safe, and effective medical interventions already exist, appropriate technology is of little benefit if it is not used by providers and is not accessible to women.