In 1994 representatives of more than 180 nations met at the International Conference on Population and Development (ICPD) and approved a Programme of Action to improve reproductive health. To help in the process of defining, implementing, and evaluating strategies to carry out the ICPD program at the request of the U.S. Agency for International Development, the Committee on Population of the National Research Council organized the Panel on Reproductive Health in Developing Countries to: (1) examine 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.
The panel began with the vision of reproductive health embodied in the ICPD:
Every sex act should be free of coercion and infection.
Every pregnancy should be intended.
Every birth should be healthy.
No population in the world has yet met these goals. Problems are particularly acute in developing countries:
Between 20 and 40 percent of births are unwanted or mistimed, posing hardships for families and jeopardizing the health of millions of women and children.
An estimated 50 million induced abortions are performed each year, with some 20 million of these performed in unsafe circumstances or by untrained providers.
Almost 600,000 women each year die due to pregnancy-related causes, 99 percent of them in developing countries. Approximately 7.6 million infants die in the perinatal period each year.
There are more than 333 million new cases of curable sexually transmitted diseases worldwide each year. Largely as a result of these infections, a high proportion of couples in some regions cannot conceive the children they want. Among those who have sexually transmitted infections who do achieve pregnancy, between 30 and 70 percent will transmit the infection to their infants, and many will deliver prematurely or suffer a miscarriage or stillbirth.
Nearly 22 million people are estimated to be infected with the human immunodeficiency virus (HIV, the virus that causes AIDS), of whom 14 million are in sub-Saharan Africa, with rapidly increasing numbers of infected persons in South and Southeast Asia. The risk of transmission of HIV through heterosexual contact is increased two-to five-fold by infection with other sexually transmitted diseases (STDs).
Although a great deal of research and experimentation with programs need to be done, there are measures available now that could have an effect on these interrelated problems. We recommend a multisectoral approach involving public services, the private sector, and policy changes. Even poor countries could make progress on the major reproductive health problems with well targeted efforts and the support of the international community.
Healthy sexuality is a vital component of reproductive health, both in its own right as an aspect of emotional and mental well-being and as a determinant of other aspects of reproductive health. Healthy sexuality should include the concept of volition and informed decision-making. Cultures differ in norms about sexuality, particularly those concerning sexual behavior of young people before marriage and women's rights to refuse unwanted sexual relations within marriage or to initiate sexual relations. But many serious health problems are caused by behavior that violates norms that are shared across cultures, such as those against sexual violence and sexual exploitation of children.
Sexuality education and communication are needed to contribute to changing norms and behavior to build images of responsible sexual behavior. Sexuality education programs do not currently reach most young people and adults, and programs that do exist often provide little
more than information about reproduction, contraception, and STDs. Evidence, albeit mainly from developed countries, suggests that well-designed sexuality education can reduce risky sexual behaviors. Curricula should include components on gender roles, self-esteem, decision making, sexual and domestic violence, and communication and negotiation skills. Information alone is seldom sufficient to produce changes in health-related behaviors. Programs will also need to be developed or strengthened to provide specific skills to health care providers and to individuals to improve sexual health.
Sexual violence and coercion are widespread problems and have serious health consequences. High priorities in every society should be identification and removal of barriers to victims' access to the law enforcement system and creation of support services for victims. Laws against sexual and domestic violence need to be enacted, and existing laws enforced. Health services have an important role in both providing counseling and treating the victims of violence. Nongovernmental organizations may have an advantage in provision of services, but government support and reforms are needed as well.
In addition to direct policies aimed at sexual violence, measures to increase women's autonomy—through higher education, opportunities for financial independence, laws guaranteeing inheritance rights and rights on the dissolution of marriage—are also likely to reduce women's vulnerability to coercion and violence.
Where female genital mutilation is common, reproductive health strategies should include, at a minimum, measures to educate the public and formal and informal health care providers about its harmful effects on women's health and to enforce existing bans on the practice. Female genital mutilation is performed on some 2 million girls each year, primarily in Africa and the Middle East. There are several variants of the practice, which is typically intended as a restraint on sexual behavior. It is usually carried out in unhygienic circumstances, most often without anesthesia, and puts girls at high risk of infection and later sexual and genitourinary problems.
INFECTION-FREE SEX AND REPRODUCTION
Reproductive tract infections (RTIs) include:
sexually transmitted diseases,
endogenous infections that result from overgrowth of organisms normally present in the reproductive tract (such as bacterial vaginosis and candidiasis), and
iatrogenic infections due to medical procedures.
These infections can have severe consequences, including enhanced HIV transmission, infertility, ectopic pregnancy, and genital neoplasia. Nearly every pathogen that is sexually transmitted can also be passed on to the fetus or infant, often with tragic consequences such as AIDS, fetal wastage, premature birth, permanent neurological impairment, or blindness.
To control STDs, we recommend a two-pronged approach to eliminate symptoms and reduce complications for individuals and to interrupt transmission of infections within a population. First, family planning, prenatal and general health services should include capability for management of symptomatic RTIs, since clinical encounters offer opportunities to treat infections among women who would not come into contact with specialized STD treatment settings. Second, services should be designed to meet the special needs of individuals whose behaviors are critical to sustaining STD transmission in communities, such as commercial sex workers and men with multiple sex partners.
Primary prevention of STDs requires changes in personal behaviors, supported by changes in community norms. For the general population, interventions should:
increase knowledge of the symptoms, signs, and consequences of STDs,
encourage delay in initiation of sex among adolescents,
promote use of condoms and other barrier methods among those who are sexually active in relationships that are not mutually monogamous, and
identify sources of quality care for suspected infections.
The campaigns that appear most successful have used a range of media, have been designed with attention to local cultural norms, and have employed audience segmentation and professional production and pretesting. Condom social marketing programs have used a range of print and broadcast media, widespread distribution, and point-of-purchase advertising to increase condom sales, even in some of the world's poorest countries. Mass media campaigns can be a valuable channel for these efforts, but alone are likely to be insufficient to catalyze widespread behavior change.
Family planning, prenatal, and primary health care facilities should ensure that symptomatic individuals can obtain appropriate management of STDs. Particularly in settings where resources are very limited, the highest priority for RTI clinical services should be the case management of STDs both because these infections most frequently result in severe complications for individuals and because, unlike other RTIs, they can spread through communities. Standardized case management using
currently available tools should be a routine responsibility of family planning and other reproductive health services. Management of STDs can and should be offered by every facility, program, or country that wishes to improve reproductive health. At a minimum, family planning and primary health care facilities should ensure that symptomatic women and men can obtain appropriate management of genital ulcers, discharge syndromes, and pelvic inflammatory disease.
The use of locally adapted versions of standardized algorithms for syndromic management developed by the World Health Organization should help achieve this goal. These algorithms do not require laboratory support and perform well for genital ulcers in both sexes and for urethritis in men. Unfortunately, the algorithms perform less well for the syndromes that are most common among women—vaginal discharge and lower abdominal pain. The performance of these algorithms may be improved using locally appropriate means to assess behavioral risk factors.
Treatment of sex partners and risk reduction counseling for infected individuals and their partners are essential to the success of STD clinical prevention services. Treatment protocols at all levels must be developed and periodically revised in light of local disease and antibiotic resistance patterns. Sentinel surveillance or special studies of etiologies of STD syndromes and antibiotic resistance patterns are needed to guide these decisions.
STD screening, regardless of symptom status, and treatment as appropriate should be provided for sex workers. Screening services require the commitment of resources for etiologic laboratory testing and for targeted outreach activities. Together with treatment of symptomatic men, STD detection and treatment among sex workers are central to limiting the spread of STDs in the community. Over time the primary and secondary prevention efforts aimed at these groups should help reduce the STD burden among clients attending family planning and other health facilities. Targeted health promotion efforts should aim at reduction in number of sex partners and risky sexual practices, together with promotion of condoms and other barrier methods, and early health care seeking. Peer counseling and skill building should be tested in more settings in developing countries.
Prenatal and delivery care should include syphilis screening and treatment during pregnancy and newborn prophylaxis for gonococcal eye infections. These are simple, inexpensive interventions that are highly cost-effective in most parts of the developing world.
Prevention of endogenous infection requires efforts to improve women's and men's knowledge of reproductive physiology, menstrual and personal hygiene, health-seeking behavior, and adherence with prescribed
therapy. Efforts should focus on reducing use of harmful intravaginal substances (i.e., douches and desiccants) and on curtailing inappropriate use of broad-spectrum, systemic antibiotics. The latter will require changing prescribing practices of both traditional and allopathic health care providers, pharmacists, and family members. Family planning and other health services should use simple, inexpensive tests of vaginal secretions for symptomatic women and provide appropriate management of endogenous RTIs.
Infection prevention, consisting of simple measures such as hand washing, appropriate use of gloves, and adequate sterilization of instruments, should be a minimum standard. Prevention of iatrogenic infection requires improvement in overall quality of reproductive health services, particularly transcervical procedures. One of the most effective ways to prevent iatrogenic RTIs is to reduce the number of unsafe abortions by improving the supply of contraceptive services, promoting the use of emergency contraception, and decriminalizing abortions.
In developing countries outside sub-Saharan Africa, between one-tenth and one-third of all recent births are reported as unwanted, and the same percentages are reported to be the result of mistimed conceptions. In Africa these percentages are typically lower, but since fertility rates are high, the proportion of women and families affected by unintended pregnancies is as high as elsewhere.
Reducing unwanted pregnancies promotes maternal health mainly by reducing the number of times that a woman is exposed to the risks of pregnancy and childbearing in poor environments. Children's health is also affected: unintended pregnancies are disproportionately in high-risk categories, and lower fertility results in increased family and social investments in health care, schooling, and nutrition for the planned children.
To meet existing and growing unmet need for contraception, access to contraceptive services should be expanded through clinical and nonclinical channels, including postpartum care and STD prevention services. Reducing unmet need for family planning through safe access to a range of contraceptive methods is a high priority for reproductive health programs. A basic task for family planning and health programs is to support informed choice by clients. Information, education, and communication programs and improvements in counseling are still needed, even where family planning programs are well established, because of gaps in the knowledge of providers, clients, and potential clients about how to
use contraceptives and the advantages and disadvantages of the methods available.
Use of contraceptive pills for emergency contraception appears safe and effective for women who have unprotected mid-cycle intercourse. Information on the techniques should be provided widely to health care and family planning staff and those who may need it.
Unsafe abortion remains a leading cause of maternal death. Access to safe means for abortion care, including early intervention to treat abortion complications, is needed to reduce the numbers of deaths. Even where abortion is legal, services are often low in quality, stigmatized, and access is difficult, making abortion needlessly dangerous. In those countries governments should ensure (through direct provision or regulation) adequate equipment and training for manual vacuum aspiration in the first trimester of pregnancy. Where medical supervision and surgical backup are feasible for medical abortions, the option should be available for first-trimester abortions. Health care and family planning providers will require training on medical abortion and contraindications. Where abortions are illegal, health services should ensure that women who have had septic and incomplete abortions are treated appropriately and promptly. Where the prevalence of infertility is high, as in much of Africa, measures to reduce infertility should be a high priority, including programs to control STDs, provision of aseptic abortion, and early treatment of septic abortion.
HEALTHY PREGNANCY AND CHILDBEARING
The major direct causes of maternal deaths in the developing world are hemorrhage, sepsis, obstructed and prolonged labor, septic abortion, and hypertensive disorders of pregnancy. Even among survivors, consequences of these conditions can be severe. It makes sense to consider maternal and perinatal health together, because both mother and child are affected by the direct causes of death and disability and because the interventions designed to promote maternal and perinatal health often overlap or are operationally linked.
Priority should be given to providing women with essential care for obstetric complications, in particular by establishing or strengthening obstetric units at hospitals. The quality and appropriateness of skills for the management of labor should be upgraded and maintained. The major causes of maternal mortality cannot be predicted or prevented well enough during pregnancy to allow reliance on primary prevention and screening for high risk. Many previous efforts to reduce maternal mortality in developing countries have foundered because they relied solely on attempts to train traditional birth attendants, screen high-risk pregnancies,
and refer women to expensive, distant, and ineffective sources of treatment. Improvements in maternal death rates will require access to facilities and trained providers and equipment in facilities that can carry out essential care of obstetric complications.
Most births in developing countries take place outside health facilities, so the most effective strategy is to ensure that complications of pregnancy and delivery are recognized once they occur and that women are taken to a facility where essential care of obstetric complications of adequate quality is provided. This strategy has four elements: First, a life-threatening complication must be recognized by the woman, her family, traditional birth attendant, or others in attendance. Second, those in attendance have to decide to seek appropriate care and then, third, get the woman to an adequate facility in time. Barriers to access currently include distance, the cost or lack of transport, cost of the services, geographical or weather constraints, and perceived poor quality or attitude of the providers. Lastly, care for obstetric complications and neonatal care in the facility have to be adequate. The few existing studies of the quality of maternity care identify major deficiencies; many preventable maternal deaths are due to inappropriate or delayed care in health facilities.
Most efforts to improve quality of care have focused on training—for example, training midwives in life-saving skills and interpersonal communication. Training of one cadre of workers is not enough to sustain improved practices. Programs must also train those to whom midwives are supposed to refer women and devise policies that allow trainees to put their new skills to use and improve management and supervision, information systems, logistics, and supplies.
Protocols for the management of obstetric and neonatal complications are useful for medical care providers to guide and coordinate their actions, know their limits and next steps. In cities in some middle-income countries, obstetric care can be too interventionist, with potential harm for the health of mothers and infants and wasting resources. Inappropriately aggressive care in urban areas often coexists with a lack of access to obstetric care in rural areas and for the poor.
Some obstetric problems may be managed or stabilized by trained midwives or other providers at a peripheral level (antibiotics for infections, sedatives for eclamptic patients) prior to referral to a site with more complete essential care of obstetric complications. How to do this effectively and for which complications are important topics for operational research.
Interventions are needed to improve community awareness of, support for, and involvement in the transportation of women with obstetric complications to facilities that can deliver essential care. Families
(and those who influence them) need to know signs of obstetric complications and where to seek care.
Reproductive health services need to include information and education programs about early recognition of signs and symptoms of obstetric complications and when and where to seek needed help. These campaigns can draw a wide variety of media, including mass communication, face-to-face communication as part of child survival or family planning programs, and existing prenatal care.
Appropriate prenatal care should include screening and treatment for syphilis, for anemia, and detection and management of pregnancy-induced hypertension. Delivery care should include neonatal prophylaxis for ophthalmia neonatorum. Postpartum care should include contraceptive counseling. Prenatal, delivery, and neonatal care provide multiple opportunities to promote reproductive health, many of which are missed opportunities when services are fragmented. Prenatal care of some kind now reaches the majority of pregnant women in developing countries and should be used to provide more effective interventions to improve both maternal and perinatal health.
PROGRAM DESIGN AND IMPLEMENTATION
Even in countries where fertility decline has already begun, the momentum of population growth ensures that there will be significant increases in the number of women aged 15-49 and rapid increases in the number of young people during the next several years. Just to keep up present inadequate levels of services would require substantial growth in absolute terms; to expand and improve services will require both increased resources and skilled management.
Although no one configuration of reproductive health services will serve all needs, a number of potentially effective clinical and nonclinical interventions can be implemented now at different levels of the health care system.
For some aspects of reproductive health, there is a good deal of experience with different types of service delivery and different scales of operation. But development of comprehensive reproductive health services will require experimentation. Research on the determinants of organizational effectiveness in provision of reproductive health care is urgently needed.
Reproductive health services should concentrate on strengthening coordination, referral, and linkage among three principal service domains of reproductive health programs: STD prevention and management; pregnancy and contraceptive services; and delivery care for both mothers and newborns.
Whether to integrate services at different levels cannot be decided in the abstract. Functional integration may increase the convenience of services for clients, increase the likelihood that their particular needs will be diagnosed and met, and minimize ''down time" for multipurpose providers. Its disadvantages come when providers are overloaded or insufficiently trained and supervised for some of their functions.
Examples of successful functional integration of reproductive health services already exist, particularly in provision of information and counseling. HIV/AIDS information and prevention messages have been incorporated into some family planning information, education, and communication efforts. Provision of information about STDs and about danger signs in pregnancy and labor, and where to go for help, should likewise be added to the duties of every service provider who comes into contact with adult women and their families.
There are also examples of successful linkage of different reproductive health services at the clinic level. In many countries, linkage with child health services is a major convenience for mothers or legitimizes what would otherwise be an embarrassing clinic visit or one considered not worth the cost.
Administrative integration in public systems is often difficult to impose. Its advantages are that it allows coordination and setting of priorities across services and that it spreads the cost of overhead services across many programs. The disadvantages are that particular functions may be neglected and managers may not feel accountable for their successful performance.
Effective reproductive health programs will require a focused and measurable set of objectives, adequate resources, and, sometimes, generation of demand for their services. Reproductive health is most likely to succeed if objectives are focused and managers held accountable for their achievement. Implementation of effective reproductive health programs will require significant and continuous building of local capacity in systems such as training, supervision, and management; procurement and distribution of supplies; information, education, and communication efforts; and record-keeping and evaluation.
Both public- and private-sector organizations have an important role to play in increasing awareness of reproductive health services and how and when to use them—particularly recognition and treatment of RTIs and pregnancy complications. Research is needed on the determinants of demand for specific components of reproductive health services, especially how women and men come to believe treatment is needed and what motivates them to seek care in various settings.
COSTS, FINANCING, AND SETTING PRIORITIES
Financial, managerial and administrative resources for health are tightly constrained in low-income countries. Recommendations for reproductive health must be considered in light of such overall resource constraints.
Reproductive health services are among the most cost-effective health investments available to both low- and middle-income countries. More research is needed at a country level on costs, as well as evaluations of effectiveness of operational scale programs.
Cost-effectiveness estimates are imprecise, but even allowing for a wide margin for error, many reproductive health interventions rank high in comparison with other potential health sector investments and should receive greater priority in health sector budgets. Analyses using cost models developed for related interventions show that costs of a package of basic interventions, relative to current health care spending, can range from modest, in moderate-income settings, to significant, in low-income settings. Cost estimates vary greatly, depending on the salary costs and the degree to which personnel and infrastructure are fully utilized and are shared with other health services. Per capita costs can be high when expensive facilities are underutilized, as is often the case. Improvements in quality of services and communicating information about their availability and benefits may help achieve operation at efficient scale.
Both costs and effectiveness will change over time, as service delivery organizations learn by doing and as increased demand for services changes the scale of operations. Cost-effectiveness studies are not a once-and-for-all effort to describe the best set of services, but a framework for continuous evaluation and redirection as reforms are introduced.
Public-sector financing need not preclude private-sector provision of reproductive health services. Subsidies should be targeted to the poor, especially in middle-income countries and for well-established services. Improvements in reproductive health are probably best achieved by a mix of public and private finance and provision, as well as other government instruments, such as mandates and regulation.
User fees are increasingly common in developing countries. While they can generate resources and spur efficiency, user fees should be implemented with caution and accompanied by monitoring and evaluation. Many of the services called for in this report are not only of community benefit rather than only individual benefit, but are also new and unfamiliar to their intended clients. Efforts to make them self-sufficient too quickly could stifle attempts to build demand. Safeguards are needed to protect access to services for the poor and services with significant public health benefits.