REPRODUCTIVE HEALTH
By: Adam F. Izzeldin; BPEH, MPH, PhD candidate.
Department of International Health, TMDU

Contents
Contents
Definition and components of reproductive health?
Demographic trends and fertility determinants
Family planning
Impact of reproductive patterns on child health
Impact of reproductive patterns on women health
Mechanisms to reduce morbidity and mortality.

What is reproductive health?
Within the framework of WHO's definition
of 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.
(WHO)

Components of reproductive health
• Family-planning counseling, information,
education, communication and services;
• Education and services for prenatal care,
safe delivery, and post-natal care, especially
breast-feeding, infant and women's health
care;
• Prevention and appropriate treatment of
infertility; abortion; sexually transmitted
diseases; and reproductive tract infections
•
information, education and counselling, as
appropriate, on human sexuality,
reproductive health and responsible
parenthood.

Reproductive health links
• Reproductive health tied to policy
concerns about population growth as
well as health.
• International Conference on Population
and Development in Cairo 1994 focused
on population while two previous
international conferences emphasized on
family planning.
• In 2000 , the United Nation Millennium
declaration was adopted as a
commitment; however, goal 5 is to
improve maternal health (by reducing
maternal mortality three quarters).

Demographic trends and fertility determinants
• World population reached 1 billion just after 1800.
• But it took less 125 years to add the second billion in
1930.
• In 1960 the world passed the third billion.
• Within 40 years ahead the population doubled to be
6 billions in 2000.
• In year 2010 the world population reached 7 bilion.
• The majority of this expansion has taken place in
developing countries.
• The encouraging news is that the rate of growth is
declining since 1960.

World population growth
Source: United nation population division

Population size by continent, 1950-2100

The world population growth rate
2010

The process of fertility
Sterility
Marriage
Effective reproductive span
Birth of
woman
Marriage
dissolution
Menarche
Start of
marriage
B1
Postpartum
amenorrhea
B2
B2
Time to
conception
Resumption
of menses
B3
B last
Time to
conception
conception
Fetal loss
End of exposure
to risk
pregnancy
conception
B3
Death of
woman

Deliberate control of fertility
1. Reducing the effective
reproductive span through
postponement of marriage or
interrupted marriage or by
sterilization that ends
reproductive capacity early.
2. Using contraception, which
increases the time to
conception.
3. Abortion, which increases the
time added to birth interval by
pregnancies that do not lead to
live birth

The effect on fertility of the proximate
determinants: Bongaart’s Indices
•
The index of postpartum infecundity:
The proportion of potential fertility, TF, when the average
of postpartum period of the population of interest is
taken into account.
•
The index of abortion:
The proportion of TF, after postpartum first taken into
account.
•
The index of contraception:
The proportion of TF, after the effect of postpartum
infecundity and induced abortion taken into account.
•
The index of marriage:
The proportion of TF, after the first three factors are
considered. TFR= TF

Family planning
• The rationale is to reduce unintended fertility
because of its negative health and welfare
consequences and because it has been recognized
as a human right .
• Over the last 50 years, the dissemination of modern
ideas bout small families was adopted.
• In part, due to lack of availability , accessibility, and
effective contraceptive, the gap between observed
and desired fertility is grew, leading to in turn to an
increase to unintended fertility.
• According to WHO, in 2005 out of 211 million
pregnancies, 87 million women became pregnant
unintentionally.

Family planning methods
Region
Sterilization
Pill
IUD
Condom
Total
Female
Male
21.0
4.0
7.0
15.0
5.0
61.0
Africa
2.0
0.1
7.0
5.0
1.0
26.0
Asia
25.0
4.0
5.0
18.0
4.0
64.0
Latin America
31.0
2.0
13.0
8.0
4.0
70.0
Oceania
12.0
9.0
21.0
2.0
9.0
59.0
Japan
3.0
0.6
0.8
1.5
43.0
56.0
Europe
4.0
2.0
16.0
15.0
10.0
67.0
Northern America
23.0
14.0
15.0
1.0
13.0
76.0
New Zealand
14.0
19.3
20.5
3.3
11.0
74.0
World
Low and middle income countries
Industrialized region

Barriers for family planning
• The economic cost of access
to services, including
transportation and supplies.
• The social cost, including
traditional constrains, and
women movement.
• Psychic cost of contraceptive
use in a society that offer little
support for small family.
• The health cost of side effects,
whiter subjective or objective,
from contraceptive use.

Consequences of unintended pregnancy
• Abortion: represents 20%
of all pregnancies (WHO
estimates 20 million unsafe
abortion annually accounts
from 13% of maternal
deaths)
• Poor infant health with high
morbidity and mortality.
• Lower investment in human
capital (allocation f
resources for education
and health).

Organization of family planning program
• Focus on commitment to achieve
program objectives and access to
adequate resources.
• Placing the family planning program
under a national supervisory council
or by establishing a separate ministry.
• Collecting data on indicators such as
contraceptive prevalence, proportion
of unwanted births, maternal
morbidity and mortality, pregnancy
complications and their management,
and actual fertility level.

Intervention levels of family planning
Health center
community
menstrual regulation or vacuum aspiration
abortion
Information, education, and communication
Surgical contraception/ post abortion
counseling and contraception
Community-based distribution
counseling and treatment of
contraceptive side effects
Social marketing of condoms and pills
Health post
Counseling/ screening for contraception
Counseling/ referral for menstrual
regulation or abortion
Inject able contraceptive/ IUD/ counseling
and treatment of contraceptive side effects
Family
planning
District Hospital
Surgical contraception
Abortion through 20 weeks
post abortion counseling and
contraception

Strategies of Bangladesh Family planning
Diagram
Strategy 1
Improving
coverage and
quality of
services ( 5
miles clinics,
free of charge
sterilization,
home service)
Strategy 2
Awareness and
motivation (
mass media,
focused
programs)
Strategy 3
Fostering
villagebased and
household
services
(outreach)
Strategy 4
Community
development and
demand creation
(improving status of
women through
other program such
as micro-credit and
education).

Impact of reproductive patterns on
child health
Reproductive pattern
Mechanism through which child health affected
First born child
Higher frequency of death (parents less experienced in child care,
poor intrauterine growth)
Higher-order children
Cumulative maternal injuries “maternal depletion syndrome” leads to
poor intrauterine growth.
Large families
Competition for limited resources (disproportionate girls)
Child born to very young
mother
Inadequate development of reproductive system causes maternal
risks, and inexperience in prenatal care and delivery
Child born to older mother
Greater risk of birth trauma and genetic abnormality
Short interbirth intervals
Inadequate maternal recovery (depletion);similar-age siblings
competition; termination of breastfeeding; low-birth, infections
Unwantedness
Conscious or unconscious neglect; child born in stressful situation
Maternal death or illness
Early termination of breastfeeding; no maternal care; disease may
be passed to child
Contraceptive use
Hormonal contraception may interrupt braestfeeding

Maternal health
• Pregnancy is one of major health
risks for women in in low-and middleincome countries.
• Nearly 536,000 women die worldwide
each year due to pregnancy related
causes, and the vast majority (99%)
of these deaths in low- and middleincome countries.
• Although these numbers are
alarming,230 million pregnancies
and approximately 118 million births
occur annually in the world in safe
reproduction.

Confusion in definitions of maternal deaths
• Definition for Maternal deaths which defined as
deaths of woman while pregnant or up to 42
days post delivery from any cause accept
accidents. (undercount deaths up to 90 days).
• Maternal risk measurements are conceptually
distinct.
1.Maternal mortality ratio: the number of maternal
deaths to the number of pregnancies (LB)
2.Maternal mortality rate: the number of maternal
deaths divided by the number of women of
reproductive age (15 – 49 years old)
3. Life time risk: chance of dying from pregnancy
related cause.

Maternal mortality risks
• In sub-Saharan Africa and South Asia, maternal
mortality ratio of 800 maternal deaths per 100,000 live
births have been reported.
• The disparity between low- and middle-income and
high-income countries is much greater for maternal
mortality ( 20 times higher risk of maternal death per
pregnancy) than infant mortality ( 10 time s higher risk
of infant death per pregnancy).
• Life-time risk of maternal mortality vary from 1/75 in
low- and middle-income countries to 1/7,300 in highincome countries.
• Maternal mortality ratios are 50 times higher (450
death/100,000 LB in low- and middle-income countries
vs. 9 deaths/100,000 LB in high-income countries )

Total Fertility Rate, Maternal Mortality Ratios, and
Lifetime Risk of Maternal Death by region,2005. source:
Population Reference Bureau (2008)
Region
Total Fertility
Maternal
Maternal Deaths
Rate (Birth per Mortality Ratio
woman)
(Deaths per
Lifetime Risk
Death per year
100,000 LB)
World
2.6
400
1 in 92
536,000
Industrialized
countries
1.7
9
1 in 7,300
960
Low- and
middle-income
2.7
450
1 in 75
533,000
Africa
4.8
820
1 in 26
276,000
Asia
2.3
330
1 in 120
241,000
Latin America
and Caribbean
2.3
130
1 in 290
15,000

Direct and indirect causes of maternal
mortality and morbidity
• Direct: related to pregnancy or
postpartum periods (hemorrhage
25%, sepsis 15%, eclampsia 12%,
complications of unsafe abortion
13%, obstructed labor and
others).
• Indirect: related to conditions
precede, but aggravated by,
pregnancy ( anemia, diabetes,
malaria, tuberculosis, cardiac
diseases, hepatitis, and
increasingly HIV) WHO,2005

Impact of reproductive patterns on
women health
Reproductive pattern
Mechanism through which maternal health is affected
Number of pregnancies
Each pregnancy carries a risk of morbidity and mortality
Higher-risk pregnancies
First-time mothers
2-4 higher risk for obstructed labor, induced hypertension, obstetric
complications due to initial adaptation
High-order pregnancies
Hemorrhage and uterine rupture and reproductive injuries
Pregnancy at very young
maternal ages
Physiological immature reproductive system and reduced timely
care seeking.
Pregnancy at old maternal
ages
Body in poor condition for pregnancy and child birth
Short interbirth intervals
Inadequate time to rebuild nutritional stores and regain energy level.
Unwanted pregnancies
ending in unsafe abortions
Increased exposure to injuries, infections, hemorrhages, and deaths
Pregnancy for women
already in poor health
Aggravated health conditions.

Mechanisms to reduce maternal
morbidity and mortality.
• Reduced exposure to pregnancy by reducing
fertility (family planning).
• Optimization of access to emergency obstetric care
(assisted virginal delivery, removal of placenta,
using vacuum extraction or aspiration, anesthesia
and cesarean section, blood transfusion, ectopic
pregnancy and safe abortion….etc).
• Improvement of general health status and treatment
of pregnancy- and childbirth-related complications
(antenatal care, postnatal care, safe motherhood,
treatment of maternal illness….etc).

Conclusion
• Improvements are needed in the quality of family
planning services, especially in the areas of
information exchange and methods choice to
reduce fertility and unwanted pregnancy.
• Maternity care needs to be significantly expanded
to , while preventive services ( including education
of both men and women in health and sexuality,
family planning, and prevention of STIs) need to be
increased.
• At societal level, programs need to be supported to
improve the status of women through education,
changes in laws, and cultures.

Thank you for listening