1

Introduction

In 1994 representatives of nearly 180 countries at the International Conference on Population and Development (ICPD) adopted a Programme of Action, a crucial section of which included a definition of reproductive health (United Nations, 1994):

Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its processes. Reproductive health therefore implies that people are able to have a 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. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for the regulation of fertility which are not against the law, and the right of access to appropriate health-care services that enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. … It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases.

Linking fertility regulation to other positive goals of reproductive health was seen as a call for change in the focus of population policy and for commitment of resources to meet previously neglected health needs. The Programme of Action entails both expansion and reform of health



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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 1 Introduction In 1994 representatives of nearly 180 countries at the International Conference on Population and Development (ICPD) adopted a Programme of Action, a crucial section of which included a definition of reproductive health (United Nations, 1994): Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its processes. Reproductive health therefore implies that people are able to have a 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. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for the regulation of fertility which are not against the law, and the right of access to appropriate health-care services that enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. … It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases. Linking fertility regulation to other positive goals of reproductive health was seen as a call for change in the focus of population policy and for commitment of resources to meet previously neglected health needs. The Programme of Action entails both expansion and reform of health

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions services, as well as action by sectors other than health to create the supportive environment for improvements in reproductive health. Implementing the Programme of Action will require improvements in the quality and range of existing services, as well as basic and applied research on new services. It will also require information on the magnitude of reproductive health problems, the effectiveness and feasibility of alternate actions to overcome the problems, and the resources needed to do so. To aid in this process, the U.S. Agency for International Development, the Andrew W. Mellon Foundation, and the William and Flora Hewlett Foundation asked the Committee on Population of the National Research Council to: (1) assess the magnitude and severity of reproductive health problems in developing countries, (2) assess the likely costs and effectiveness of interventions to improve reproductive health, and (3) recommend priorities for programs and research. To carry out this task, the Research Council formed the Panel on Reproductive Health in Developing Countries. THE PANEL'S FRAMEWORK To organize our research and presentation, the panel adopted the ICPD's vision of reproductive health: Every sex act should be free of coercion and infection. Every pregnancy should be intended. Every birth should be healthy. This vision is also consonant with other widely used definitions of reproductive health (see Fathalla, 1988; Germain and Antrobus, 1989). No population in the world has attained the state of health described by the ICPD definition quoted above nor fully realized the vision adopted by the panel. By stating the goals positively, rather than in terms of reduction in morbidity, mortality, and other forms of suffering, we emphasize health and a broad focus. We consider social and behavioral change and policy changes, as well as programs targeted directly against particular causes of illness and death. Improving reproductive health involves social and cultural influences and the behavior of individuals and their families, at least as much as delivery of services by public and private agencies to their clients. This report should be useful for those who design reproductive health programs in developing countries, set priorities for funding them, and conduct or fund research to improve programs. The geographic focus of this report is primarily the low- and middle-income countries of Asia, the Pacific islands, Africa, Latin America, and the Caribbean basin. However,

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions many of the conclusions and recommendations are also relevant to the formerly socialist countries in transition to market economies and to high-income countries. Reproductive health overlaps with, but is not the same as, women's health. Reproductive health includes the health of men; reproductive rights include men's rights. However, the programmatic discussion in the following chapters deals more with women than with men, for several reasons. For example, sexually transmitted diseases are more often recognized and treated among men than among women, and the challenge for policy is to design services that reach women effectively and appropriately. Sexual violence and circumcision are more serious threats to health for women than for men. Abortion, pregnancy care, and safe delivery all have more direct effect on women's health than on men's, although men's views and behavior affect these aspects of reproductive health. Most problems and interventions we discuss below cannot simply be classified as women's health or men's health. Prevention of sexual coercion, condom use for prevention of sexually transmitted diseases (STDs), prevention of infertility, provision of contraceptive methods, and communication of information for health promotion are all measures to improve the sexual and reproductive health of both women and men. And pregnancy and delivery care, education in general, and sexuality education can improve the health and development of all children. THE CHALLENGES Many of the barriers to achieving reproductive health in developing countries described in this report exist in developed countries as well, but the problems are particularly acute in the developing countries. Nearly 90 percent of all the births in the world occur in developing countries—115 million births per year. These 115 million births are the outcomes of about 180 million pregnancies. A significant proportion of these births—about one-fifth—are unintended. An estimated 50 million induced abortions are performed each year, with some 20 million of these performed in unsafe circumstances or by untrained providers. There are estimated to be more than 333 million new cases of curable sexually transmitted diseases worldwide each year. Partly as a result of these infections, an unknown, but in some countries tragically high, number of couples cannot have the children they want. Almost 600,000 women each year die from pregnancy-related causes (complications of pregnancy, delivery, puerperium, or abortion), 99 percent of them in developing countries. About 1 in 48 women in developing countries dies from these causes, compared with only about 1 in 1,800 women in developed countries.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Some 7.6 million infants die in the perinatal period each year. Far larger numbers of women and their children survive the reproductive process but with disabilities that may profoundly affect their lives. The imprecision of such estimates, and the lack of any statistics for some of the problems discussed in this report, are due in part to the lack of past attention to research and measurement of these problems. Gaps in knowledge of the extent of problems are also due to inadequate health services at crucial stages of reproduction. Millions of women do not receive adequate delivery care. Their deaths, the vast majority of which are preventable, are due to lack of contact with health care providers, or late contact, or inadequate action after contact. Millions of women and men do not have the knowledge about, or access to, family planning and safe abortion that would help them make and implement informed choices about fertility. Millions of people lack knowledge about, or access to, services that would help them avoid infections that can permanently affect their health, including their fertility. One immediate challenge for reproductive health is the sheer growth in the size of the populations to be served. Even in countries in which declines in fertility have begun, there will still be rapid increases in the number of women aged 15-49 and in the number of young people during the next few years. The challenge is particularly daunting for countries with poorly developed family planning services—those with very low prevalence of modern contraception. All of these countries are projected to have increases of 50 percent from 1995 to 2010 in their population of women aged 15-49; see Table 1-1. (The population of men in these high-fertility years, not shown in Table 1-1, will also increase by almost exactly the same proportions as the population of women.) Just to continue present inadequate levels of services would require very rapid growth in absolute terms; to expand and improve the quality and range of services will require both increased resources and skilled management. In countries in which health and family planning services are better established (again, the proxy measure is the contraceptive prevalence rate), less effort will be required to match the expected growth rate of the populations to be served. In Colombia, for example, the number of adult women will increase by less than one-fourth over the 15-year span, and the number of young people by one-tenth. In Thailand, the number of young people will actually decrease. This does not mean that Colombia and Thailand do not need resources and policy attention for reproductive health: The epidemic of AIDS and other STDs, the need to improve quality of other reproductive health programs, and the need to reach previously underserved populations present major challenges. However, these

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions TABLE 1-1 Projected Increases in Number of Women Aged 15-49, Number of Persons Aged 15-24, and Percentage of Population Living in Cities, Selected Countries, 1995-2010  Country % Increase in Number of Women Aged 15-49 % Increase in Population Aged 15-24 % Urban       1995 2010 Low Contraceptive         Prevalence (<20%)         Ghana 62 63 36 47 Nigeria 59 64 39 51 Pakistan 65 68 35 45 Tanzania 58 55 24 36 Zambia 56 58 43 50           Medium Contraceptive       Prevalence (20-45%)         Bangladesh 46 20 18 28 Bolivia 45 37 61 72 Cameroon 60 52 45 57 India 34 24 27 34 Kenya 66 56 28 39 Zimbabwe 49 48 32 44           High Contraceptive         Prevalence (>45%)         Indonesia 26 3 35 50 Colombia 22 10 73 79 Thailand 10 -13 20 27   SOURCE: United Nations (1995a, 1995b); medium variant projections. tasks can be undertaken against a background of relatively stable population growth. Rapid urbanization is the other demographic change that is affecting the populations that are the focus of this report. In all the countries shown in Table 1-1, the urban population is growing much more rapidly than the rural population, due to migration, natural increase, and the reclassification of growing towns as cities. In some ways the increasing concentration of populations should make the provision of high-quality reproductive health services easier, particularly for services such as clinical contraception and safe delivery care, which have always been hard to deliver among dispersed populations. But many programs will have to adapt models of community-based services that were developed for largely rural societies for urban populations.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions SCOPE OF THE REPORT The panel's work builds in many ways on the report of the Committee on Population's Working Group on Health Effects of Contraception and Reproduction (National Research Council, 1989), which strengthened the scientific understanding of associations of fertility patterns and family planning with infant and maternal health. Like the former working group, the panel attaches particular significance to the view that reproductive health concerns the entire life-cycle. Some reproductive health problems have their origins in insufficient investment in nutrition, health care, and education early in childhood and adolescence. Gender inequities in these investments by parents and society at large have long-lasting, harmful effects. Some reproductive health problems have consequences for women's health during and after menopause. Reproductive health is thus not confined to what are considered the "reproductive years." The panel neither adopted nor rejected the framework of reproductive rights that guided much of the discussion before and during the ICPD, nor did we adopt the approach of defining rights to health care, education, or other basic needs.1 The human rights approach can be very important as a way to define international agreement and hold governments accountable for their actions or inactions. But our aim is more modest: given considerable agreement about the goals, as shown by the willingness of nearly 180 governments to sign the ICPD Programme of Action, what can we say about practical next steps that can be taken within 5-10 years to bring all countries closer to the goals? Though we do not define a single minimum package of reproductive health interventions, we argue that there are steps that can be taken in all settings, even where rights to health care, and many other rights, are realized only very imperfectly. Several topics implied by a broad definition of reproductive or sexual health are not encompassed in the framework used by the panel. These include problems of sexual dysfunction (except insofar as these would be improved by measures against coercion and infection or by increased confidence in control over fertility) and cancers of the reproductive organs (except for some consideration of STD prevention and treatment as a cost-effective measure for prevention of cervical cancer). Many diseases and conditions prevalent in developing countries, such as malaria, are 1   The Universal Declaration of Rights, for example, includes "the highest attainable standard of physical and mental health" (United Nations, 1973).

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions aggravated by pregnancy: we include as reproductive health those programs that help prevent pregnancy but not those that disrupt malaria transmission. The framework we use does not include actions to improve child survival after the first week of life, though many of the interventions we discuss (improved pregnancy and delivery care and child spacing and fertility limitation) would have positive effects on child health. For practical purposes, the panel concentrated on health problems for which causes, consequences, and effective remedies are linked programmatically. We recognize that in drawing limits around our subject we risk neglecting some useful linkages. The boundaries around our topics should be considered permeable membranes, not rigid walls. The next four chapters of this report follow the sequence suggested by our organizing framework, dealing with healthy sexuality (Chapter 2), infection-free sex (Chapter 3), intended pregnancies and births (Chapter 4), and healthy pregnancy and delivery (Chapter 5). Each chapter discusses both the magnitude of problems and what is known about the effectiveness of interventions. The next two chapters deal with themes that link the interventions: program design and delivery (Chapter 6) and costs and financing (Chapter 7). A recurring theme in this report is the need for more research. Although enough is already known to move programs and policies in more effective directions, continued organizational learning and adaptation is still needed. This need spans the spectrum from development of new diagnostic tools, pharmaceuticals, and contraceptives to field trials, survey measurement of reproductive morbidities and risk behaviors, operations research, and cost-effectiveness analysis of interventions. The panel finds good reason to believe that the investment in this research will pay off in terms of improved quality of life, especially for the people who are now the least well served.