Woman health final 2022 (1) (1).pdf

Woman’s Health
Under supervision of
Assist. Prof. / Samia Ibrahim Osman
Assist ,prof. of Woman's Health and Midwifery Nursing,
Faculty of Nursing, Mansoura University.
Assist. Prof. / Amal Ahmed Yousef
Assist ,prof. of Woman's Health and Midwifery Nursing,
Prepared by
Woman’s health and Midwifery students nursing
department students
2022 – 2023
Mansoura University
Faculty of Nursing
Credit Hour Doctorate Course
2021-2022
Woman's Health and Midwifery Nursing
Department

Violence, abuse and harassment
Assist prof. Samia Ibrahim Osman
At Woman’s Health & Midwifery Nursing Department
Faculty of Nursing- Mansoura University
Prepared by
Nourhan Magdy Nasr
Sara Zenhom Zenhom
2022/2023
Mansoura University
Faculty of Nursing
2022-2023
Department

Objectives
General objective
By the end of the lecture, each post graduate student will be able to acquire
knowledge, practice and attitude about violence, abuse and sexual harassment
against women.
Specific objectives
By the end of the lecture, each post graduate student will be able to;
➢ Definition of Violence
➢ Define Intimate partner violence
➢ List causes and risk factors for intimate partner violence
➢ Identify the Cycle of Violence
➢ Identify power and control wheel (violence wheel)
➢ Mention the health consequences of intimate partner violence
➢ Define abuse
➢ Discuss types of Abuse.
➢ Explain violence during pregnancy
➢ Discuss nursing Management of Intimate Partner Violence
➢ Define stalking
➢ List guide lines for stalking
➢ Define sexual violence.
➢ List the potential impact of rape
➢ List steps of reducing risk of rape
➢ Define stranger violence
➢ List consequences and steps of reducing stranger violence
➢ Define sexual harassment
➢ Mention steps of dealing with sexual harassment
➢ Discuss prevention of violence against women
➢ WHO global plan of action on strengthening the role of the health
systems in addressing interpersonal violence, in particular against
women and girls and against children.

Outline
➢ Definition of Violence
➢ Definition Intimate partner violence
➢ Causes and risk factors for intimate partner violence
➢ The Cycle of Violence
➢ The health consequences of intimate partner violence
➢ Power and control wheel (violence wheel)
➢ Definition and types of Abuse.
➢ Violence during pregnancy
➢ Nursing Management of Intimate Partner Violence
➢ Sexual violence (rape definition, impact and reducing risk of rape).
➢ Stranger violence
➢ Sexual harassment
➢ Prevention of violence against women
➢ WHO global plan of action on strengthening the role of the health
➢ References.

Introduction
Violence against women – particularly intimate partner violence and sexual
violence is a major public health problem and a violation of women's
human rights. Estimates published by (WHO 2021) indicate that globally
about 1 in 3 (30%) of women worldwide have been subjected to either
physical and/or sexual intimate partner violence or non-partner sexual
violence in their lifetime. Most of this violence is intimate partner violence.
Worldwide, almost one third (27%) of women aged 15-49 years who have
been in a relationship report that they have been subjected to some form of
physical and/or sexual violence by their intimate partner.
Violence can negatively affect women’s physical, mental, sexual, and
reproductive health, and may increase the risk of acquiring HIV in some
settings. Violence against women is preventable. The health sector has an
important role to play to provide comprehensive health care to women
subjected to violence, and as an entry point for referring women to other
support services they may need.
Violence: Is the intentional use of physical force against another person,
group or community so as to injure, abuse, damage or destroy.
Intimate partner violence(IPV)
Intimate partner violence is one of the most common forms of violence
against women and includes physical, sexual, and emotional abuse and
controlling behaviors by an intimate partner.
Causes and risk factors for intimate partner violence
➢ Female gender, younger age.
➢ Presence of a physical or mental disability
➢ Use of alcohol.

➢ Lower socioeconomic status in which the abuser is unemployed or a
lower level of academic achievement.
➢ Homeless women have higher rates of violence over the life span than
women with stable housing.
➢ Immigrant women are also a vulnerable population, as they may be
afraid to reveal IPV, fearing deportation of themselves and/or their
spouse.
The Cycle of Violence
In an abusive relationship, the cycle of violence comprises three distinct
phases: the tension-building phase, the acute battering phase, and the
honeymoon phase
Phase 1: Tension building
During the first and usually the longest phase of the cycle, tension increases
between the couple. Excessive drinking, jealousy, or other factors might
lead to name-calling, hostility, and friction. The woman might sense that
her partner is reacting to her more negatively, that he is on edge and reacts
angrily to any minor issues. She internalizes her sense of responsibility for
preventing the situation from exploding. In her mind, if she does her job
well, he remains calm. But if she fails, the resulting violence is her fault.
Phase 2 : Acute battering
The second phase of the cycle is the explosion of violence. The batterer
loses control both physically and emotionally. After a battering episode,
most victims consider themselves lucky that the abuse was not worse, no
matter how severe their injuries. They often deny the seriousness of their
injuries and refuse to seek medical treatment.

Phase 3: Honeymoon
The third phase of the cycle is a period of calm, loving, and regretful
behavior on the part of the batterer. He may be truly sorry for the pain he
caused his partner. He believes he can control himself and never hurt the
woman he loves. The victim wants to believe that her partner really can
change. She feels responsible for causing the incident, and she feels
responsible for her partner’s well-being.
Health consequences of intimate partner violence
1- Injury and physical health
The physical damage resulting from IPV can include: bruises; lacerations
and abrasions; abdominal or thoracic injuries; fractures and broken bones
or teeth; sight and hearing damage; head injury; and back and neck injury.
2- Mental health and suicide
Evidence suggests that women who are abused by their partners suffer
higher levels of depression, emotional distress, thoughts of suicide, anxiety
and phobias than non-abused women.
3- Sexual and reproductive health
IPV may lead to a host of negative sexual and reproductive health
consequences for women, including unintended and unwanted pregnancy,
abortion and unsafe abortion, sexually transmitted infections including
HIV, pregnancy complications, pelvic inflammatory disease, urinary tract
infections and sexual dysfunction.

Power and control wheel (violence wheel)
The wheel is a heuristic tool that focuses on how eight different types of
abuser tactics partner with physical and sexual violence (or the threat of
physical and sexual violence) to dominate a victim. The wheel is made up
of these component parts:
• Physical and Sexual Violence (outer ring)
• Using Intimidation
• Using Emotional Abuse
• Using Isolation
• Minimizing, Denying and Blaming
• Using Children
• Using Male Privilege
• Using Economic Abuse
• Using Coercion and Threats

Abuse:
Abuse is almost any behavior inflicted by a perpetrator that
causes us distress or harm
Types of Abuse
1- Emotional Abuse includes:
➢ Promising, swearing, or threatening to hit the victim
➢ Threatening to harm children, pets, or close friends
➢ Threatening to leave her and the children
➢ Isolation from family and friends
2- Physical Abuse includes:
➢ Hitting the victim so hard that it leaves marks
➢ Throwing things at the victim
➢ Spitting at, biting, burning, pushing, choking the victim
➢ Attacking the victim with a knife, gun, rope, or electrical cord
➢ Controlling access to health care for injury
3- Financial Abuse includes:
➢ Preventing the woman from getting a job.
➢ Controlling how all money is spent
➢ Failing to contribute financially
4- Sexual Abuse includes:
➢ Forcing the woman to have vaginal, oral, or anal intercourse
against her will
➢ Forcing the victim to perform sexual acts on other people or
animals.

Violence during pregnancy
Women assaulted during pregnancy are at risk for:
➢ Injuries to themselves and the fetus
➢ Depression, Panic disorder
➢ Chronic anxiety, Insomnia
➢ Miscarriage
➢ Stillbirth
➢ Poor nutrition
➢ Placental abruption
➢ Excessive weight gain or loss
➢ Smoking and substance abuse
➢ Delayed or no prenatal care
➢ Preterm labor and low-birth-weight infants
➢ Higher rate of surgical births
➢ Sexually transmitted infections (STIs)
➢ Urinary tract infections
➢ Fetal and maternal deaths
Nursing Management of Intimate Partner Violence
1- Assessment
➢ Routine screening for IPV is the first way to detect abuse. The nurse
should build rapport by listening and showing an interest in the concerns
of the woman.
➢ Communicating support and telling the woman that no one deserves to
be abuse are first steps toward establishing trust and rapport.
❖ Screen for abuse during every health care visit
Screening for violence takes only a few minutes and can have a positive
effect on the outcome for the abused woman, the following clues may be
helpful:

➢ Injuries: The same as previously mentioned.
➢ Mental health problems :The same as previously mentioned
➢ Frequent tranquilizer or sedative use
➢ Delay in seeking medical attention.
➢ STIs or pelvic inflammatory disease
➢ Appears nervous, ashamed when asked questions
➢ Partner’s behavior at the health care visit: appears overly concerned or
overprotective, is unwilling to leave her alone with the health care
provider, answers questions for her, and attempts to control the
situation.
❖ Isolate client immediately from family
The assessment can take place anywhere that is private and away from the
abuser, for example, x-ray area, ultrasound room, elevator or laboratory.
❖ Ask direct or indirect questions about abuse
Ask difficult questions in an empathetic and nonthreatening manner and
remain nonjudgmental in all responses and interactions. Choose the type
of question that makes you most comfortable. Direct and indirect questions
produce the same results. “Does your partner hit you?” or “Have you ever
been or are you now in an abusive relationship?” are direct questions. If
that approach feels uncomfortable, try indirect questions: “Many women
in our community experience abuse from their partners. Is that what is
happening to you?”
❖ Assess immediate safety: It is essential to assist the woman by
assessing her safety and the safety of her children.

Interventions
➢ A modified tool—the ABCDES— provides a framework for
providing sensitive nursing interventions to abused women. Specific
nursing interventions for the abused woman include educating her
about community services, providing emotional support, and
offering a safety plan.
The ABCDES of caring for abused women:
❖ A is reassuring the woman that she is not alone. The isolation by her
abuser keeps her from knowing that others are in the same situation and
that health care providers can help her.
❖ B is expressing the belief that violence against women is not acceptable
in any situation and that it is not her fault.
❖ C is confidentiality. Assure her that you will not release her information
without her permission.
❖ D is documentation, which includes the following:
• A clear quoted statement about the abuse in the woman’s own words
• Accurate descriptions of injuries and the history of them
• Photos of the injuries (with the woman’s consent)
❖ E is education about the cycle of violence and that it will escalate:
• Educate about abuse and its health effects.
• Offer appropriate community support and referrals:
• Display posters and brochures to foster awareness of this public
health problem.
❖ S is safety, the most important aspect of the intervention, to ensure that
the woman has resources and a plan of action to carry out when she
decides to leave.

Offer a safety plan
Nurses cannot choose a life for the victim; they can only offer choices.
Women planning to leave an abusive relationship should have a safety
plan, if possible
Safety plan for leaving an abusive relationship
When leaving an abusive relationship, take the following items:
• Driver’s license or photo ID
• Social Security number /work permit
• Birth certificates for victim and her children
• Phone numbers for social services or women’s shelter
• The lease to her home or apartment
• Any court papers.
• A change of clothing for her and her children
• Checkbook, credit cards, and cash
• Health insurance cards.
Stalking
Generally refers to harassing or threatening behavior that an individual
engages in repeatedly, such as following a person, appearing at a person’s
home or place of business, making harassing phone calls, leaving written
messages or objects, or vandalizing a person’s property.
Guidelines for women who are being stalked: The guidelines do not guarantee
her safety, but may reduce her risk of harm.
➢ Record each incident of stalking with great detail. Save any messages a
stalker leaves, and write details of any conversations or encounters.

These records can be used as evidence against the perpetrator if
necessary.
➢ Let family and friends know about the stalker. This protects not only
the victim but also those close to the victim.
➢ Inquire about the state’s stalking laws. Each state’s laws differ; see how
they apply to this specific case.
➢ Other preventive measures include: changing the locks on doors; adding
extra outside light around the residence; staying in public places when
out of the house; and informing neighbors so they can alert someone if
they see something suspicious.
Sexual violence:
Sexual violence is "any sexual act, attempt to obtain a sexual act, or other
act directed against a person’s sexuality using coercion, by any person
regardless of their relationship to the victim, in any setting.
It includes rape, defined as the physically forced or otherwise coerced
penetration of the mouth, vagina or anus with a penis, other body part or
object, without the consent of the victim.
The potential impact of rape: -
➢ Emotional: - Depression, fear, anxiety, lack of trust, withdrawn, shame,
self-blame, guilt, humiliation, anger, perception of the world as
malevolent, low self-worth, phobias.
➢ Physical: Headaches, muscle tension, gastro-intestinal upset, genito-
urinary complaints, pregnancy, injuries.
➢ Behavioral: Suicidal actions, anorexia, alcohol and drug addiction,
isolation, eating disorders, sleeping disorders, nightmares
Reducing risk of rape and sexual assault

➢ Know your sexual intentions and limits. You have the right to say
“NO” to any unwanted sexual contact. If you are uncertain of what you
want, ask your partner to respect your feelings.
➢ Communicate with your partner. Do not assume that someone will
automatically know how you feel or will eventually “get the message”
without you having to say anything. Just as it’s okay to say “NO” to
unwanted activities, it’s okay - and important - to give clear consent to
activities in which you would like to engage. Avoid giving “mixed
messages.
➢ Be aware that some people mistakenly believe drinking, dressing
provocatively, or going to your or someone else’s room means you are
willing to have sex. Be clear up front about your limits in such
situations.
➢ Listen to your gut feelings. If you feel uncomfortable or think you
might be at risk, leave the situation immediately and go to a safe place.
➢ If you feel you are being pressured or coerced into sexual activity, you
have a right to state your feelings &/or leave the situation.
➢ Attend large parties with friends you trust. Leave with the group, not
alone. Avoid leaving with people that you don’t know very well.
➢ Attend a workshop on sexual assault risk reduction or take a self-
defense course such as the RAD (Rape Aggression Defense) class learn
additional general safety and risk reduction strategies.
Violence by strangers
Stranger violence is assaults and attempts in which the victim don’t
know the offender.
Acquainted violence is assaults and attempts in which the victim know
one or more of the offenders by sight not include partners, household
members or relatives.
Consequences of stranger violence:

➢ Feeling as if the incident is happening again, constant thoughts
about the event and nightmares
➢ Depression, withdrawal from family and friends, not being able to
go back to work, self-medication with alcohol and drugs.
➢ Anger, irritability, sleep problems and difficulty concentrating
Reducing risk of stranger violence:
➢ Walk in well- lit areas at night and with friend if possible
➢ Carry a charged cell phone
➢ Carry a whistle, bell, personal alarm and mini flash light to call
attention to yourself and request help
➢ Let someone know where you are going, when you will be
expected back, which routes, stores and direction you are going.
Sexual harassment
Sexual harassment is an illegal, violent act involving unwanted sexual
attention, requests of sexual favors, or the use of sexual language or
behaviors to create a hostile environment. Although sexual harassment can
occur in any setting, it most commonly occurs in the workplace.
Sexual harassment often involves a male harasser and a female victim.
However, sexual harassment recognizes no gender boundaries—a female
may harass a male, and the victim and the harasser may be the same sex.
Dealing effectively with harassment
➢ Explain to the person that the behavior is unwanted.
➢ Keep a record of what happened. Be as specific as possible. Include
anything you have said or did to stop the behavior. The record can be
used to make a formal complaint.

Sexual harassment law in Egypt;
A penalty of detention for a period not less than two years and not
exceeding four years and a fine of not less than LE 100,000 and not
exceeding LE 200,000
If the felony recurs once again the penalty shall be detention for not less
than three years, and not exceeding five years, and a fine of not less than
LE 200,000 and not exceeding LE 300,000
Prevention of violence against women
❖ Primary prevention
Aim
Stop violence before it occurs. It is the most effective form of Prevention
but the most difficult to achieve. The aim is to change social norms that
contribute to violence-supportive attitudes and behaviors.
Examples of primary prevention activities
Individual
1. Increase understanding of violence within family
2. Reduce social isolation
3. Challenge beliefs, values and attitudes that support violence
Family / relation ship
1. Promote positive parenting practices.
2. Build problem solving and / or conflict management skills.
3. Develop non – violent norms within relationships and families and
communicate these norms to others.
Community
1. Mobilize community members to take a stand against violence

2. Run community campaigns, events and media.
3. Promote the benefits of living free from violence.
4. Build connections between neighbors.
Societal
1. Implement policies and actions that decrease gender, ethnic and
economic inequalities.
2. Investing in Gender Equality and Women’s Empowerment
➢ Improving girls’ access to quality and safe education particularly
at the secondary or higher levels.
➢ Increasing women’s access to and control over economic
resources, including income and assets such as land and
property, inherit as well as women’s opportunities to work in safe
spaces with equal wages and protection against exploitation and
abuse.
3. Strengthen laws that address violence.
4. Challenge social norms that support violence.
5. Decrease violence in the media.
❖ Secondary prevention
Aim
Immediate responses to violence, often in a crisis situation. It is often
thought of as applying to individual victims and perpetrators, but the
concept has wider applicability.
For victims
It aims to minimize the short-term harms of violence, as well as the risk
of revictimization
For example: Emergency services for treatment for sexually transmitted
diseases following a rape.

For perpetrators
Aimed at preventing escalation of violent behaviors
❖ Tertiary prevention
Tertiary prevention focuses on long-term care in the wake of violence,
such as rehabilitation and reintegration of perpetrators, and attempts to
lessen trauma or reduce the long-term disability associated with violence
e.g.
1- Psychological therapies for abused women and children.
2-Support services for victims of intimate partner violence.
WHO global plan of action on strengthening the role of the health
• Building the evidence base on the size and nature of violence against
women in different settings and supporting countries' efforts to
document and measure this violence and its consequences, including
improving the methods for measuring violence against women in the
context of monitoring for the Sustainable Development Goals.
• Strengthening research and capacity to assess interventions to
prevent and respond to violence against women.
• Undertaking interventions research to test and identify effective
health sector interventions to address violence against women.
• Developing guidelines and implementation tools for strengthening
the health sector response to intimate partner and sexual violence
and synthesizing evidence on what works to prevent such violence.
• Supporting countries and partners to implement the global plan of
action on violence and monitoring progress including through
documentation of lessons learned.
• Collaborating with international agencies and organizations to
reduce and eliminate violence globally through initiatives such as
the Sexual Violence Research Initiative, together for Girls.

References
• Yaya, S., Hudani, A., Buh, A., & Bishwajit, G. (2019). Prevalence and
predictors of intimate partner violence among married women in
Egypt. Journal of interpersonal violence, 0886260519888196.
• Australian Institute of Health and Welfare. (2018). Family, domestic and
sexual violence in Australia, 2018.
• Murray, S. S; Mckinney, E. S;Holub, K. S and Jones, R (2019).
Foundations of Maternal-Newborn and Women’s Health Nursing. 7th edn.
PART V Women's Health Care. China, Elsevier Co, pp.718 - 776.
• Weissbecker, I., & Clark, C. (2007). The impact of violence and abuse on
women's physical health: Can trauma‐informed treatment make a
difference?. Journal of Community Psychology, 35(7), 909-923.
• Meyer, S. R., Stöckl, H., Vorfeld, C., Kamenov, K., & García-Moreno, C.
(2022). A scoping review of measurement of violence against women and
disability. PloS one, 17(1), e0263020.

Menopause and Hormone Therapy
Assist prof. Samia Ibrahim Osman
Assistant professor of Woman’s Health & Midwifery Nursing
Department, Faculty of Nursing, Mansoura University
Prepared by
Eman Nabil Ibrahim
2022/2023
Mansoura University
Faculty of Nursing
2022-2023
Department

Objectives
General objective
At the end of this lecture, each postgraduate student will acquire knowledge, skills
and attitude toward menopause and hormone replacement therapy.
Specific objectives
➢ Define menopause.
➢ Identify stages of menopause
➢ Enumerate types of Menopause
➢ Describe the physical and psychological changes associated with
menopause.
➢ Explain Current nonmedical and medical menopause management
options.
➢ List the major forms of hormone replacement therapy, as well as their
potential benefits and health risks.
➢ Discuss nursing considerations for menopausal women.

Outlines
➢ Introduction
➢ Definition of menopause
➢ Stages of menopause.
➢ Types of Menopause
➢ Symptoms of menopause.
➢ Current nonmedical and medical menopause management options.
➢ Hormonal Replacement therapy.
➢ Nursing Considerations for menopausal women.

Introduction
When a woman permanently stops having menstrual periods, she has
reached the stage of life called menopause. Often called the change of life,
this stage signals the end of a woman's ability to have children. Many
healthcare providers actually use the term menopause to refer to the period
of time when a woman's hormone levels start to change. Menopause is said
to be complete when menstrual periods have ceased for one continuous
year.
The transition phase before menopause is often referred to as
perimenopause. During this transition time before menopause, the supply
of mature eggs in a woman's ovaries diminishes and ovulation becomes
irregular. At the same time, the production of estrogen and progesterone
decreases. It is the big drop in estrogen levels that causes most of the
symptoms of menopause.
Definition of Menopause
Menopause is defined as a physiological event characterized by
ovarian failure due to loss of ovarian follicular function accompanied by
estrogen deficiency resulting in permanent cessation of menstruation and
loss of reproductive function
Stages of Menopause
1. Perimenopause “Menopausal Transition”
The transitional stage immediately before menopause. Precedes
menopause by approximately 4 years and is characterized by menstrual
irregularity (such as variation in length of menstrual cycle caused by

increase in FSH levels) with associated endocrinologic changes and
symptoms of hypoestrogenism.
2. Menopause:
Menopause is Permanent cessation of menses for at least one year due to
loss of ovarian follicular activity and reduced production of sex hormones.
3. Post-menopause
These are the years after menopause. Menopausal symptoms such as hot
flashes usually ease. But health risks related to the loss of estrogen increase
as the woman gets older and lasts the rest of a woman’s life.
Types of Menopause:
1. Natural menopause: occur spontaneously and results from ovarian
failure and estrogen deficiency occur at 51.5 years (45-55).
2. Premature menopause: when the final menstrual period occurs before
the age of 40, if this happens spontaneously it is called premature ovarian
failure.
3. Early menopause: when the final period occurs between the ages of 40-
45
4. Induced menopause:
➢ Surgical menopause (after removal of both ovaries).
➢ Radiological menopause (after irradiation of the ovaries).
➢ After administration of chemotherapy to treat malignant diseases.

Age of the natural menopause:
➢ The average age of menopause is about 51.5 years (45-55).
➢ Menopause before the age of 40 years is termed premature ovarian
failure or premature menopause.
➢ Early menopause is a potential risk factor for cardiovascular disease.
➢ Menopause is considered “late” when it occurs after age 55. Late
menopause may provide a moderate protective effect for premature
death.
Biology of Natural Menopause
1. Hormonal changes during the menopause:
• As the age of the woman advances, the ovarian reserve declines and the
trophic hormones from the hypothalamus and pituitary (FSH and LH)
increases.
The hormonal changes during the menopause include:
• FSH increases about 13 folds (menopausal level of FSH is above
40mIU/mL).
• LH increases about 3 folds.
• Marked decrease in estradiol, minimal decrease in estrogen.
• Rise in androgens levels.
• No ovarian progesterone (no ovulation).
–
2. Anatomical changes during the menopause:
• The tissues become dry, thin and less elastic because of estrogen lack.
• The ovaries become small and fibrous.
• The uterus becomes smaller
• The vagina looks pale with loss of rugae and acidity.

• Atrophy of the labiae majorae
• The ligaments become weak with tendency to prolapse and/or stress
incontinence.
• Atrophy of the urinary tract epithelium possibly with increased
susceptibility to urinary tract infection.
• The breasts become small and flabby.
3. Physiological changes during menopause:
• Hot flushes.
• Osteoporosis (decrease in bone mineral density).
• Disturbance in lipids ratio resulting in increase astherosclerotic
changes and cardiovascular ischemia.
Symptoms Frequently Associated with Menopause
(Menopausal syndrome):
• Hormonal changes during menopause affect women physically and
emotionally.
• About 50% of women do not develop these symptoms.
• Duration and severity vary with different women.
Vasomotor:
• Hot flushes
➢ Hot flashes are uncomfortable sensations of internally generated heat,
beginning in the chest and moving to the neck and head, or spreading
throughout the body.
➢ Increased heart rate and temperature, shallow breathing, and sweating
followed by chills are common during hot flashes.

➢ Hot flashes often begin before a woman has stopped menstruating, and
then continue for several years after menopause. Early hot flashes can
be an acute sign of estrogen deficiency.
➢ These are the most characteristic symptom. They can last for few
seconds up to 30 minutes and may occur at night & disturbing sleep.
• Gastrointestinal: constipation and abdominal distension.
• Urinary: frequency of micturition, dysuria, stress incontinence and
predisposition to urinary tract infections.
• Dyspareunia.
• Hirsutism.
• Uterine prolapse.
Nervous and psychological:
Palpitation. Headache.
Sleep disturbances. Dizziness.
Nervousness, Anxiety, Irritability. Depression.
Impaired concentration / confusion. Forgetfulness.
Loss of confidence. Psychosexual dysfunction.
Relationship problems.

Long -term consequences of menopause:
❖ Osteoporosis
Women are greatly affected by osteoporosis after menopause.
Osteoporosis is a condition in which bone mass declines to such an extent
that fractures occur with minimal trauma. Most women with osteoporosis
don’t know they have the disease until they sustain a fracture, usually of
the wrist or hip.
❖ Cardiovascular disease (CVD)
Myocardial infarction and stroke are the primary clinical endpoints. CVD
is the most common cause of death in women over 60. For the first half of
a woman’s life, estrogen seems to be a protective substance for the
cardiovascular system by smoothing, relaxing, and dilating blood vessels.
It even helps boost HDL and lower LDL levels, helping to keep the arteries
clean from plaque accumulation. But when estrogen levels plummet as
women age and experience menopause, the incidence of cardiovascular
disease increases dramatically.
Menopause is not the only factor that increases a woman’s risk for
cardiovascular disease. Lifestyle and medical history factors such as the
following play a major role:
 High cholesterol levels
 Family history of cardiovascular disease
 Hypertension
 Diabetes
 Smoking
 Obesity
 High-fat diet
 Sedentary lifestyle
❖ Urogenital atrophy
Vaginal atrophy occurs during menopause because of declining estrogen
levels. These changes include thinning of the vaginal walls, an increase in

pH, irritation, increased susceptibility to infection, dyspareunia (difficult
or painful sexual intercourse), loss of lubrication with intercourse, vaginal
dryness, and a decrease in sexual desire related to these changes. Decreased
estrogen levels can also influence a woman’s sexual function as well.
❖ weight gain
Estrogen appears to help regulate body weight; with lower estrogen levels,
metabolic rates drop and it is easier to gain weight. However, other factors
also influence weight gain during this time. Some women become less
active and exercise less as they age. Physical inactivity leads to lost muscle
mass, which also decreases resting metabolism, making it easier to gain
weight.
Diagnosis of Menopause:
Menopausal syndrome can be confirmed by checking the level of
FSH and LH.
• Persistent high level of FSH (above 40 mIU/mL) is diagnostic of
menopause.
• Determination of bone mineral density and bone mass to exclude
osteoporosis.
Management of Menopausal Syndrome
 Medical management options
• Sedatives, tranquilizers or antidepressants are to be given only if needed.
• Vaginal estrogen: To relieve vaginal dryness, estrogen can be
administered directly to the vagina using a vaginal cream, tablet or ring.
This treatment releases just a small amount of estrogen, which is absorbed
by the vaginal tissues. It can help relieve vaginal dryness, discomfort with
intercourse and some urinary symptoms.

Hormone Replacement Therapy
Hormone replacement therapy (HRT) is supplementing women with
hormones that are lost during the menopausal transition. To relieve the
symptoms associated with menopause, conventional HRT includes an
estrogen and progesterone component to mimic hormones created by the
human ovary.
Indications for HRT
• Symptomatic menopausal women to relieve menopausal symptoms.
• Premature or induced menopause.
• To prevent osteoporosis for a minority of women with one or more risk
factor.
• The beneficial effects operate only during treatment and disappear with
cessation of therapy.
Risks of HRT
• Venous thromboembolism : Risk is increased with combined HRT
and incidence is higher in first year of life .
• Breast cancer: combined HRT has a higher incidence than estrogen
only HRT.
• Stroke: Increase the risk to a lower extent, but the risk is very low
below 60 years.
• Coronary heart disease: incidence is lower in women under the age
of 60 years, but higher over the age of 60 years.
• Endometrial cancer: Estrogen part of combined HRT increases the
incidence of endometrial cancer, but progesterone component reduces
it.

Contraindications of HRT
A. Absolute contraindication
• Thrombo embolic disorders.
• Ischaemic heart diseases.
• Active hepatitis.
• Undiagnosed abnormal uterine bleeding.
• Breast cancer or family history of breast cancer.
• Genital tract malignancy or the family history.
A. Relative contra indications
• Uterine fibroids
• Migraine.
• Endometriosis
o HRT use should not exceed 5 years.
Hormone Therapy includes:
✓ Estrogens:
Estrogen alone regimen: is to be used only for hysterectomized
women.
✓ Estrogen - Progesterone therapy .
✓ Tibolone
✓ Androgen replacement therapy.
✓ Selective estrogen receptors modulators.
❖ Estrogens:
➢ Oral preparations : These have more powerful effect on lipid
metabolism.
➢ Transdermal preparations: provides more steady level plasma
estradiol and avoid hepatic first pass.
• Estraderm (estradiol TTS Patch).

• Estradiol skin gel (3mg/ day).
• Estaspray( dermal spray).
➢ Vaginal preparations:
• Premarin gel.
• Evalon gel.
• E2 gel.
❖ Estrogen - Progesterone therapy: for intact uterus.
Estrogen (Premarin- 0.625 mg/day).
Progesterone is used to provide uterine protection and to minimize side
effects ( uterine bleeding).
❖ Tibolone :
It is more effective in treating vasomotor and urogenital symptoms than
estrogen therapy. It improves sexuality and prevents osteoporosis.
Associated with increased incidence of breast cancer.
❖ Androgen replacement therapy:
Androgen insufficiencies include diminished energy, depression and
impaired sexuality and are increased risk of hypoactive sexual desire
disorder.
This therapy available in the form of transdermal testosterone patch;
transdermal testosterone gel. It causes increased libido, mood sense of
well-being, decreased breast tenderness due to hormone therapy.
❖ Selective estrogen receptors modulators:
➢ Tamoxifen Citrate: It improves bone mass but increase
endometrial thickening and risk of endometrial carcinoma.
➢ Raloxifen : act as estrogen partial agonist in bones and CVS , but
an antagonist in breast and uterine endometrium.

Follow up of Women using Hormone Replacement Therapy
Women using HRT should be monitored by:
➢ Periodic mammography.
➢ Pap smear yearly.
➢ Bone densitometry.
➢ Endometrial assessment by ultrasound and/or biopsy for cases with
abnormal bleeding patterns to avoid delayed diagnosis of
endometrial carcinoma.
 Non-Medical management options
Assurance about the physiological nature of the symptoms may be the
only treatment needed.
Lifestyle modifications
A healthy lifestyle can help to reduce symptoms of menopause
1. Exercise
o Being physically active helps with stress and mood
o Exercise has beneficial effects on hot flashes, well-being, Body Mass
Index (BMI) and Coronary Heart Diseases risks.
o Activities that stimulate the brain can help rejuvenate memory such as
doing crossword puzzles, longhand mathematics, and reading books.
o Pelvic floor muscle exercises, called Kegel exercises, can improve some
forms of urinary incontinence.
2. Diet
o A nutritious diet helps with fatigue and moodiness.
o A healthy diet, low in fat, high in fiber, with plenty of fruits, vegetables,
and whole-grain foods.
o Intake of foods with phytoestrogen.

Phytoestrogens are estrogen-like substances found in some cereals,
vegetables, legumes (including soy), and herbs.
The first widely attributed health benefit of phytoestrogen consumption
was relief from vasomotor perimenopausal symptoms, including hot
flushes and night sweats.
o Ensure enough calcium and vitamin D intake on regular basis.
o Avoid smoking and alcohol, as it is known to make hot flushes worse.
o Foods that should be avoided in menopause:
• Caffeine
• Spicy foods
Social support
• Social interactions with family and community and healthy emotional
support from friends are very effective means.
• A professional help from a counselor and mental health professional is
quite effective and must be readily available.
Nursing considerations and care for menopausal women
o Motivate menopausal woman to adopt healthier lifestyles by stopping
smoking and introducing weight loss initiatives.
o Listen for women and encourage expression of physical and psychological
aspects of menopause and provide emotional support to women.
o Encourage women who take HRT to make regular follow-up.
o Assess whether menopausal symptoms are being effectively controlled by
the prescribed therapy and if there are any side effects or bleeding
problems.
o Assess if there are any changes in the medical history or medication that
may potentially contraindicate the use of HRT.

o The nurse should check blood pressure at each visit and all women should
be encouraged to attend for routine cervical screening and
mammography.
o The nurse should instruct the woman about drug regimens and side
effects, including complementary therapies.
Climate Changes and Menopause
Climate change is expected to impact the health of women and men
differently, particularly in low-and middle-income countries. For example,
rising temperatures could substantially worsen the health impacts of
menopause, notably hot flashes. it is expected to affect men and women
due to biological, socioeconomic and cultural factors. In particular, heat
stress uniquely affects women because they have a compromised ability to
thermo regulate during pregnancy and around menopause. This could
reduce their ability to respond or adapt physiologically to a warming
climate.
Hot flashes are the most common symptom of menopause,
characterized by a sudden feeling of heat. This symptom is often so
unbearable, especially during the summer months, so that women seek
medical attention. Decreased estrogen levels cause the hypothalamus to
become more sensitive to changes in body temperature, increasing the
frequency and intensity of hot flashes.

How to Manage Hot Flashes in the summer
The combination of seasonal heat, humidity, and hot flashes makes
summer so unbearable for women in menopause. During this trying time,
making key lifestyle changes can relieve summer hot flashes.
• Dress in layers
When body temperature starts to rise, remove layers to cool
down. Natural fabrics, such as cotton, linen, silk, and flax are
lighter and more breathable than synthetic fabrics. Once the hot flash
fades and the chilling occurs, wear layers again.
• Diet
It is important to understand the common triggers of hot flashes.
Try to reflect on diet and see if consuming too much alcohol,
caffeine, hot beverages, and spicy foods. Make sure to also avoid
processed foods, as they tend to heighten blood pressure, which
could then increase the chances of hot flashes to occur.
• Foods that are known to have a protective effect against hot flashes.
Incorporating these foods into diet could support hormonal balance.
❖ Soy Products
• Soybeans
• Soy Milk
❖ Phytoestrogen-rich foods
• Berries - Carrots
• Apples - Wheat
❖ Omega-3 Fatty Acids
• Sardines - Salmon
• Flaxseeds - Avocados

❖ Cooling Foods
• Cucumber - Radish
• Watermelon.
Older people may be less able to look after themselves during
extreme weather. Older people are often more severely affected from
the impacts of heat waves than other groups in the community, as
they may:
Drink less water, as they feel less thirsty with age, so are likely to
become dehydrated in heat
Have existing health conditions
Be socially isolated
Not gain enough sleep on hot nights to recover.
Climate change affects health through a multitude of mechanisms,
including heat, poor air quality, and extreme weather events, as well as
through meteorological changes that alter vector-borne disease, reduce
water quality, and decrease food security. Rising average temperatures and
more frequent periods of heat waves will likely impact diet and eating
behaviors, physical activity, sleep, and substance use.
Considering physical activity, some studies have demonstrated that
warmer temperatures have a positive effect on physical activity, in colder
countries or during winter, conversely, physical activity levels are known
to be low in countries with extremely warm temperatures. Sleep can also
be affected by warmer temperatures. A systematic review found that
increases in night time temperatures are likely to amplify sleep
disturbances and obstructive sleep apnea, particularly among elderly and
low-income populations.

The presence of potentially harmful substances in the air is a major
environmental risk for health and is intimately tied to climate change (The
effect of air pollution on health can be direct (e.g., development of chronic
and acute respiratory diseases) or indirect, notably through its effect on
health-related behaviors.

References
1. Alexander, L. L. LaRosa, J. H. Bader, H. Garfield, S. &Alexander, W.
J. (2017). New Dimensions in Women's Health. 7th
edn. United State of
America, Jones and Bartlett Learning LLC Co.
2. Lowdermilk, D. L. Perry, S. E. Cashion, K. Alden, K. R. &Olshansky,
E. F. (2016). Maternity & Women's Health Care. 11th
edn. UNIT 2,
Women’s Health. China, Evolve Elsevier Co, pp.59 - 264.
3. Murray, S. S; Mckinney, E. S;Holub, K. S and Jones, R (2019).
Foundations of Maternal-Newborn and Women’s Health Nursing. 7th
edn.
PART V Women's Health Care. China, Elsevier Co, pp.718 - 776.

The Economics of woman's health
Under supervision
Assist. Prof/ Samia Ibrahim Osman
Assistant professor of Woman’s Health & Midwifery Nursing
Department, Faculty of Nursing, Mansoura University
Prepared by
Ghada Gamal Mohamed
2023
Mansoura University
Faculty of Nursing
2022-2023
Department

Objectives
General Objectives
At the end of this lecture, each post graduate student will be able to upgrade
knowledge, practice and attitude regarding the economics of women's
health.
Specific Objectives
At the end of this lecture, each post graduate student will be able to:
1. Define Health economics.
2. Explain Health System in Egypt.
3- Explain Levels of Health Care
4- Discuss Maternal Health Care Program in Egypt.
5- Explain the impact of health reform on women’s health

Outline
• Health economics
• Health System in Egypt
• Levels of Health Care
• Maternal Health Care Program in Egypt
• Importance of economics of Women’s Health.
• Health Insurance
o Woman's Health Insurance.
o Types of health insurance
o Health Insurance in Egypt
o Health initiatives to improve woman's health
o The challenges that confront the health system to achieve the
goal of the Ministry of Health and Population (MOHP) of
improving health of all citizens.
• Health Care Reform
o Definition of health care reform
o Egypt Health Sector Reform Program (HSRP)
o The basic goals of a healthcare system reform
o Health Care Reform for women
o Principles for Health Reform to Improve Women’s Lives

Introduction
The cost of health services may prevent women from accessing adequate
health care services. Approximately 5% of Egyptian women are covered
by health insurance. In order to enhance the health condition of women in
general, and that of marginalized women in particular, it is necessary to
expand the umbrella of health insurance provision and improve its services.
Definitions
 Health Economics is a branch of economics concerned with issues
related to efficiency, effectiveness, value and behavior in the
production and consumption of health and health care.
 Health care is the maintenance or improvement of health via the
diagnosis, treatment and prevention of disease, illness, injury, and other
physical and mental impairments in human beings.
 Health services is all services dealing with the diagnosis and treatment
of disease, or the promotion, maintenance and restoration of health.
They include personal and non-personal health services.
 Health care systems are organizations, people, institutions, and
resources arranged together in accordance with established policies, to
deliver health care services to meet the health needs of target
populations.
Health care systems can be categorized as inpatient Vs outpatient care
Inpatient care: Patients stay in a medical facility for at least one night
e.g. serious illnesses or medical issues that require substantial
monitoring.
Outpatient care: Patient is examined, diagnosed, or treated at a
medical facility but doesn't stay overnight e.g. X-rays, MRIs, CT
scans, Lab tests and Consultations or follow-ups with a specialist.

Health Care System in Egypt
Healthcare in Egypt consists of both a public and a private sector. For
several decades, the government has provided a subsidized healthcare
system that is meant to ensure health care for those who cannot afford it
Private Sector
Semi-governmental
Sector
Governmental
Sector
Management
Items
-Private practice
doctors.
-pharmacists.
-Non-governmental
organizations.
- Clinics in mosques
and churches.
-Health Insurance
Organizations.
-Curative Care
Organization.
-Ministry of Health
and Population
(MOHP) facilities.
-University facilities.
-Teaching hospitals.
-Hospitals affiliated
with the Ministries of
Defense and Interior.
Type of health
facilities/
providers
User fees.
Ministry of Finance
and cost-recovery.
Ministry of Finance
and self–funding
from the economic
departments
Source of
funds
Low-, middle-, and
high-income people
Middle- and high-
income people.
Low-and middle-
income population
Served
population
MOHP, Medical
Syndicate, and
Ministry of Social
Solidarity
MOHP
MOHP
Registration

Levels of Health Care
1. Primary health care
- Primary health care is a people-centered rather than disease-centered
service that addresses the majority of a person’s health needs throughout
their lifetime including physical, mental and social well-being.
- Primary care is generally the first level of care that patients receive when
they have medical concerns or needs and takes a whole-of-society
approach that includes health promotion, disease prevention, treatment,
rehabilitation and palliative care.
The World Health Organization attributes the provision of essential
primary care as an integral component of an inclusive primary health
care strategy and suggests that a primary care approach should
include the following three components:
1. Meeting people’s health needs throughout their lives;
2. Addressing the broader determinants of health through multi-sectoral
policy and action; and
3. Empowering individuals, families and communities to take charge of
their own health.
2. Secondary health care
▪ Secondary health care provides a higher level of curative care than
PHC.
▪ Health services are provided by specialists in general and district
hospitals and polyclinics.
▪ A referral system exists between primary care and secondary care
facilities. Secondary level of care is more costly.
3. Tertiary health care
Tertiary health care provides an advanced level of health-care and
technology through specialized hospitals and institutions and distinguished

health-care specialists. It covers five percent of the community health
needs. Tertiary level of care is expensive.
4. Quaternary Care
▪ The last form of healthcare is quaternary, and it is an extension of
tertiary care.
▪ Quaternary care is not offered at every hospital as it requires highly-
advanced equipment and procedures.
▪ It’s not a usual form of patient care as it is only employed when
traditional treatments fail to ease a patient’s symptoms.
▪ It might include drug trials and experimental medical treatments.
Maternal Health Care Program in Egypt
Components of the Maternal Health Care Program
• Antenatal care (ANC)
• Natal care
• Postnatal care and inter-pregnancy care
Sources of Maternal Health Services in Egypt
• In urban areas – Maternal and child health centers and the general urban
health centers.
• In rural areas – Rural health units, rural health centers, and integrated
hospitals (rural health hospitals).
Antenatal Care Program
Antenatal care is a type of preventive healthcare. It is provided in the form
of medical checkups, consisting of recommendations on managing a
healthy lifestyle and the provision of medical information.
Consists of
• Registration and record keeping
• Periodic visits and clinical examination including laboratory tests
• Health education and care

• Tetanus toxoid immunization
• Risk detection and management
• Referral services (if needed)
• Home visits
• Social care
1. Natal Care Program
 Objectives of natal care
• Ensure a clean and safe delivery
• Preserve the health of the mother and the child
• Prevent delivery-related complications
• Ensure timely access to emergency care, when needed
Components of natal care
-Birth attendants – Well-trained physicians or nurses should be the
persons who assist the delivery. In communities that have a traditional birth
attendant (TBA) as the only person who assists labor, the TBA should be
trained for safe and clean delivery as well as risk detection and referral.
-Place of delivery – Delivery should take place in a well-equipped health
facility. Hospital deliveries are preferred. However, there are well-prepared
delivery rooms in some PHC facilities that have medical transportation
facilities for emergency cases.
2. Postnatal Care (Postpartum Care) program
World health organization (WHO) stated that postnatal care is defined as a
care given to the mother and her newborn baby immediately after the birth
of the placenta and for the first six weeks of life.
The postpartum period is composed of three phases.
❖ Immediate postpartum period (the first 24 hours after childbirth)
❖ Early postpartum period (the first week after childbirth).
❖ Late postpartum period (the second through the sixth week after
childbirth).

Goals of postnatal care
o Ensure the good health of the mother
o Ensure the good health of the newborn
o Family planning for birth spacing
Health insurance
Health insurance is a type of insurance that covers medical expenses that
arise due to an illness. These expenses could be related to hospitalization
costs, cost of medicines or doctor consultation fees.
Women’s health insurance is medical coverage with benefits
specifically designed to provide care and services that may be excluded by
other plans and policies. The importance of health insurance for women
cannot be stressed enough, as recent reports show that between the private
and public sector, over 10% of women are uninsured, which means they
don’t have access to the benefits they need.
Related definitions to health insurance
Out-of-Pocket
The amount of money a patient pays for medical expenses that are not
covered by a health insurance plan. Out-of-pocket costs include
deductibles, coinsurance, and copayments.
Deductibles
The amount you pay for covered health care services before your insurance
plan starts to pay. With a $2,000 deductible, for example, you pay the first
$2,000 of covered services. After you pay your deductible, you usually pay
only a copayment or coinsurance for covered services.

Co-pays
A co-pay is a fixed out-of-pocket amount paid by an insured for covered
services. It is a standard part of many health insurance plans. Insurance
providers often charge co-pays for services such as doctor visits or
prescriptions drugs. Co- pays usually paid at the time of service.
Co-insurance.
Co-insurance is a percentage of a medical charge that you pay, with the rest
paid by your health insurance plan that typically applies after your
deductible has been met. For example, if you have a 20% co-insurance, you
pay 20% of each medical bill and your health insurance will cover 80%.
Model of the typical health care
Money
Service
Model of a health care with an insurer
Financing rules payment rules
Access rules
Types of
Types of health insurance
1. Public health insurance
A program run by U.S. federal, state, or local governments in which
people have some or all of their healthcare costs paid for by the
government. The two main types of public health insurance are Medicare
and Medicaid.
Patient provider
Insure
r
provider
patient

Medicare
Medicare is a federal health insurance program available for people aged
65 years or older. The program is also for younger people with certain
disabilities it applies to the qualified individual and not an entire family.
Medicaid
Medicaid covers low-income people who don't have the financial
means to afford healthcare on the private services, regardless of age.
Medicaid covers basic health care costs such as visits to the doctor and
hospital stays, but can also cover things like the cost of eyeglasses.
2. Private health insurance
Private health insurance refers to any health insurance coverage that
is not offered by a state or federal government. Instead, private health
insurance is offered by a private entity, such as an insurance company.
Health Insurance in Egypt
Egypt has two main insurance providers that operate under government
supervision but with independent administration and financing. They are
the Health Insurance Organization (HIO) and Curative Care
Organization (CCO).
1- The Health Insurance Organization (HIO) is the primary provider of
insurance in Egypt, established by the Ministry of Health and
Population (MOHP) in 1964 with intent to provide health insurance
coverage to all Egyptians.
▪ The HIO covers employed persons, students and widows through
premiums deducted from employee salaries and employer payrolls. The
HIO operates an entire network of hospitals, and at times will contract
with private health care providers in order to fill gaps in its coverage
network.

▪ The current value of out of pocket health spending is 59.6%. According
to Egypt vision 2020, the target is that out of pocket health spending
decreases to 40 % and by 2030 decrease to 28%.
2- The Curative Care Organization (CCO).
Operates in specific Egyptian governorates (Cairo, Alexandria, Port Said,
Kalyubia, Damietta and Kafr el Sheikh). It contracts with individuals,
companies and government agencies for the provision of care and arranges
premiums accordingly.
The New Health Insurance Plan in Egypt
The Egyptian Ministry of Health announced the implementation of the new
comprehensive health insurance system in the coastal governorate of Port
Said to offer better health services to citizens. The new system will cover
all governorates by 2032.
❖ The medical services that will be covered by the comprehensive health
insurance.
The comprehensive health insurance system covers all medical services for
the beneficiaries, from the initial medical examination, through imaging
and medical tests, to major medical and surgical interventions critical and
urgent including open-heart surgery, bone-marrow transplants, kidney
and liver specialties, neurology and micro-surgery.
❖ The preventive services for women that most health insurance plans
must cover.
▪ Anemia screening on a routine basis for pregnant women.
▪ Breast cancer genetic test (BRCA) counseling for women at higher
risk for breast cancer.
▪ Breast cancer mammography screenings every 1 to 2 years for
women over 40.
▪ Breast cancer chemoprevention counseling for women at higher risk.

▪ Breastfeeding comprehensive support and counseling from trained
providers, as well as access to breastfeeding supplies, for pregnant and
nursing women.
▪ Cervical cancer screening for sexually active women.
▪ Domestic and interpersonal violence screening and counseling for
all women.
▪ Folic acid supplements, Urinary tract or other infection and Tobacco
use screening for women who may become pregnant.
▪ Gestational diabetes screening for women 24 to 28 weeks pregnant
and those at high risk of developing gestational diabetes
▪ Osteoporosis screening for women over age 60 depending on risk
factors.
▪ Sexually Transmitted Diseases (STD) screening for all pregnant
women or other women at increased risk.
Examples of Health Initiatives to Improve Woman's Health
1. The 100 Million Health Initiative
The 100 Million Health Initiative launched in October 2018, aimed to
screen more than 52 million citizens for hepatitis C (HCV). The Health
Ministry has vowed to completely eliminate the disease from Egypt by
2022.
So far, Egypt has succeeded in examining more than 60 million citizens
under the umbrella of the health initiative, and provided free
nationwide treatment through government centers for more than one
million citizens struck by the virus.
2. Egyptian Women’s Health Initiative
▪ Under the brand “Egypt’s Women are Egypt’s health”, the first
phase of a Presidential campaign to support women’s health began
in nine governorates: South Sinai, Matrouh, Port Said, Alexandria,
Beheira, Damietta, Qalyubiya, Fayoum, and Assiut.

▪ The initiative targets 27 million women over the age of 18 and will
be carried out in three stages.
▪ The duration of the check-up is 15 minutes, preceded by a 30
minutes awareness lecture on methods of detection, home
inspection, healthier lifestyles and reproductive health, alongside
stressing the importance of periodic examination for each woman
and performing medical tests and analysis of diseases such as
diabetes, and blood pressure and weight checks.
3. Women’s Health Outreach Program
The project of the mobile health care unit for women sought to make
a CT scan for women in Egypt over the age of forty-five for early
discovery of breast cancer, in addition to raising preventive medical
awareness and joying of the total health care.
Health Consequences in Absence of Health Insurance
• Poorer quality of health care, lower rates of preventive care, and greater
probability of death.
• Uninsured adults are more than 25 percent more likely to die prematurely
than adults with health insurance.
• Many uninsured people avoid seeking medical care unless they are faced
with an emergency, or they delay care until their symptoms become
intolerable.
• The uninsured are less likely to receive a diagnosis in the early stages of a
disease and are more likely to suffer complications from aggravated
medical conditions.
• People who don’t have insurance are more likely to receive an initial
diagnosis of cancer in a late stage of the disease, and tend to have poorer
treatment outcomes and to die within less time after diagnosis.

• Uninsured people are also less likely to receive a timely diagnosis or
treatment of sexually transmitted diseases, which can develop into serious
health conditions and an increased risk of contracting HIV.
• Uninsured people who are HIV-positive are less likely to be aware of their
HIV status and are likely not to seek treatment until the disease has
progressed.
• People who lack health insurance are more likely than the insured to die
from trauma or other acute conditions, such as heart attacks or strokes.
The challenges that confront the health system to achieve the goal of the
Ministry of Health and Population (MOHP) of improving health of all
citizens:
1. Inadequate expenditure on health.
2. Inefficient health insurance system.
3. Inefficient management of the health system at MOHP level is due to
the centralized control, extensive infrastructure, and governmental
responsibility for health care for all individuals and extensive
governmental involvement in the pharmaceutical sector.
4. Complex organizational structure of the health system: There are
multiple public and private sources of finance and delivery of health care
and limited governmental oversight of the private sector.
5. Inefficient health services delivery: Shortcomings in human resources
include low capacities and skills, mal-distribution of physicians across
geographic regions and specialties and insufficient salaries and incentives.
6. Disease Burden: Due to demographic and epidemiologic and nutrition
transition, Egypt has a very long list of health problems: high rate of
population growth, endemic and infectious diseases, high maternal and
child morbidity and mortality, chronic/non-communicable diseases.

7. Shortage in Basic public services: unsatisfactory environmental
indicators related to housing, slums, shortage of safe water, sewage
disposal, and air pollution contribute in increasing morbidity and mortality.
In response to the shortcomings of the health system, Egypt launched the
Health Sector Reform Program (HSRP) in 1997.
Health Care Reform
Definition of health care reform
Any proposal that will change the way medical care is paid for and
delivered to a population. While there is a growing consensus that change
is necessary in our health care system, there is not agreement among
stakeholders including policymakers, insurance companies, employers,
health care providers, and consumers on exactly what that change should
be or how it should happen.
Egypt Health Sector Reform Program (HSRP) is a program to transform
Egypt’s health sector between 1997 and 2020, with the overall goal of
shifting the focus of health care from a high dependence on vertical
programs and inpatient care to a more integrated and less expensive,
quality, universally accessible, and sustainable primary healthcare
The basic goals of a healthcare system reform
▪ Improving population health status and social well-being.
▪ Ensuring equity and access to care.
▪ Ensuring efficiency in the use of resources.
▪ Enhancing clinical effectiveness, improving quality of care and
consumer satisfaction, and assuring the system’s long-term financial
sustainability.

The importance of health care reforms for women
There are a number of reasons that health reform is important for woman.
• Women have distinct health care needs.
Women are more likely than men to require health care throughout their
lives, including regular visits to reproductive health care providers, they
are more likely to have chronic conditions that require continuous health
care treatment and certain mental health problems affect women more than
men.
• Health insurance is a critical factor in making health care accessible,
but women face unique barriers to obtaining coverage that is
affordable.
• Women are more likely than men to report problems getting health
care due to cost.
Women have lower incomes than men, both insured and uninsured women
are more likely to delay or avoid getting the care they need because they
cannot afford it, and they are also more likely to struggle with medical debt
or bills.
• Improves preventive care for providing evidence-based preventive
services at no cost for women – including annual mammograms and well-
woman visits, birth control, and breast feeding support.
• Women have a major role in decisions about health care for their
entire families, and they often play a significant role in the health care
that their children, spouses, or parents receive.
Women make approximately 80 percent of all family health care
decisions. Most of women report that they assume primary responsibility
for decisions about health insurance plans for their families.

Principles for Health Reform to Improve Women’s Lives
1. Ensure Equity in Health Care Coverage
▪ Health reform must ensure there are no gaps in access to care.
▪ Regardless of age, race, gender, disability, geographic location, or
employment status, there must be equity in health care access,
treatment, research, and resources.
2. Ensure that Health care is affordable for all.
▪ Health reform should ensure that individuals, as well as businesses,
have affordable and predictable health costs.
▪ Health insurance premiums should not be based on factors such as
gender or health status.
3. Ensure Comprehensive Benefits.
People need both to stay healthy and to be treated when they are ill
regardless of the individual’s stage of life.
▪ This includes coverage of preventative services; a full range of
reproductive health services including abortion; treatment needed for
serious and chronic diseases and conditions; and appropriate end-of-
life-care.
4. Build Accountability into any Health Care System.
Any plan for health reform should include a watchdog role for government
to ensure that risk is spread fairly among all health care payers and that
health insurance companies do not improperly delay or deny coverage for
health care, turn people away, establish or raise rates, or drop coverage
based on a person’s health history, age, or gender.
5. Effectively Control Health Care Costs.
▪ Health reform plans must adopt effective cost controls that promote
quality, lower administrative costs, and provide long-term financial
sustainability.

▪ Provisions should include use of standard claims forms, secure
electronic medical records that adequately protect patient privacy, the
use of the public’s purchasing power to instill greater reliance on
evidence-based protocols and lower drug and device prices, and better
management and treatment of chronic diseases.
Policies are implementing to Improve Women’s Health
Payment Reform.
Ministry of health will implement at least one payment reform policy
related to maternal health. Among these, the most common value-based
payment policy is reduced payment or nonpayment for procedures that are
not medically indicated, such as cesarean sections.
Models of Care Delivery
Ministry of health will incorporate at least one of the following care
delivery models: (1) care coordination/case management as a benefit for
high-risk pregnancies; (2) group prenatal care; and (3) pregnancy or
maternity medical homes.
Managed care organizations (MCO) Data Reporting Requirements.
Ministry of health will using managed care has integrated maternal health
data reporting requirements into MCO contracts. Common performance
measures include timeliness of prenatal care, frequency of ongoing
prenatal care, postpartum care, and smoking cessation.
Midwifery-Led Care.
The Affordable Care Act is mandated that all insurance plans must cover
licensed or certified midwives. Midwives are equally reimbursed for
equivalent services provided by physicians and hospitals.
Doula Services.
Doula services, widely known for improving birth outcomes and
experiences for communities with low-incomes, are now covered by
Medicaid statewide or through pilot programs or separate state funds.

Postpartum Coverage Expansion.
Postpartum Coverage Expansion has introduced legislation to support
postpartum coverage . The postpartum period provides a key opportunity
to address maternal health.
Changes in Telemedicine.
Pregnancy-related care in their telemedicine laws. Although the
Department of Health and Human Services increased flexibilities around
telehealth access and coverage during the public health emergency,
expanded telemedicine policies to specifically include pregnancy-related
care or enhance midwifery services
Provider Bias Training
Ministry of health is interest in addressing institutional racism in care
delivery and implementing evidence-based provider bias training programs
within the perinatal care continuum to close gaps in maternal health
disparities.

References
4. Murray, S. S; Mckinney, E. S;Holub, K. S and Jones, R (2019).
Foundations of Maternal-Newborn and Women’s Health Nursing. 7th
edn. PART V Women's Health Care. China, Elsevier Co, pp.718 - 776.
5. Nan H. T., Patricia .M. W. & Suzanne. R. (2019). AWHONN's High-
Risk & Critical Care Obstetrics, Wolters Kluwer; Arley, Alabama.
6. Luqman, M., & Khan, S. U. (2021). Geospatial application to assess
the accessibility to the health facilities in Egypt. The Egyptian Journal
of Remote Sensing and Space Science.
7. World Health Organization. Primary Health Care. Available from:
https://www.who.int/health-topics/primary-health-care#tab=tab_1
(accessed 1010 2022)
8. WHO Regional Office for Europe. Primary health care throughout our
life. Available from: https://youtu.be/uVNlez_IgdI [last accessed
9/10/2022]
9. World Health Organization (WHO). What is Primary Care . Available
from: https://youtu.be/_EXy9DTDJu8 [last accessed 10/10/12022]
10.Alexander, L. L. La Rosa, J. H. Bader, H. Garfield, S. &Alexander, W.
J. (2020). New Dimensions in Women's Health. 7th
edn. United State of
America, Jones and Bartlett Learning LLC Co.
9.Lowdermilk, D. L. Perry, S. E. Cashion, K. Alden, K. R. &Olshansky, E.
F. (2016). Maternity & Women's Health Care. 11th
edn. UNIT 2, Women’s
Health. China, Evolve Elsevier Co, pp.59 - 264.
10. Khanal,P .Improving Maternal Health Outcomes: State Policy Actions
and Opportunities.
Availablefrom:https://www.chcs.org/resource/improving-maternal-
health-outcomes-state-policy-actions-and-opportunities/ [last accessed
14/12/2022]
11.Ferrada-Videla, M., Dubois, S., & Pepin, J. (2021, May). The strategic

leadership of nursing directorates in the context of healthcare system
reform. In Healthcare Management Forum (Vol. 34, No. 3, pp. 131-
136). Sage CA: Los Angeles, CA: SAGE Publications.

Introduction to women’s health
Dr/ Samia Ibrahim Osman
Assist. Prof. of Woman's Health and Midwifery Nursing,
Dr/ Amal Yousif Ahmed
Assist. Prof. of Woman's Health and Midwifery Nursing,
Prepared by
Ahlam Mohamed Hasanein Allam
2022/2023
Mansoura University
Faculty of Nursing
2022-2023
Department

Intended Learning Outcomes (ILOs)
General ILOs
At the end of this lecture, each post graduate student will be able to
upgrade knowledge, practice and attitude regarding women’s health.
Specific ILOs
At the end of this lecture, each post graduate student will be able to:
➢ Define
• Reproductive health
• Reproductive health care
• Reproductive rights
• Sexual health
➢ Discuss access to health care providers, services, and
health information
➢ Identify global perspective on women’s health

Outline
➢ Introduction
➢ Definition of
• Reproductive health
• Reproductive health care
• Reproductive rights
• Sexual health
➢ Access to health care providers, services and health
information
➢ Global perspective on women’s health
• Maternal mortality
• Access to reproductive health services
• Family planning services
• Abortion services access
• Obstetric fistula
• Female genital cutting
• Child marriage

Introduction
The focus of reproductive rights has been on protecting the reproductive
rights of women, and reproductive rights are part of women’s rights. For
biological and social reasons, women are more directly affected than men by
decisions with respect to reproduction decisions which in turn are shaped by
issues related to gender equality, stereo typical gender roles and the role of women
in society more broadly.
Reproductive rights matters are crucially important to women as they affect
women’s mental and physical integrity, their health and sexual autonomy, “their
ability to enter and end relationships, their education and job training, their ability
to provide for their families, and their ability to negotiate work-family conflicts
in institutions organized on the basis of traditional sex-role assumptions.
Definition
Reproductive Health is a state of complete physical, mental and social
wellbeing, not merely the absence of disease or infirmity, in all matters relating
to the reproductive system and to its functions and processes.
Reproductive Health Care is defined as the collections of methods, techniques
and services that contribute to reproductive health and well-being by preventing
and solving reproductive health problems. Reproductive health care includes
care for sexual health, the purpose of which is the enhancement of life and
personal relations, and not merely counselling and care related to reproduction
and sexually transmitted diseases.
Sexual Health deals with the enhancement of life and personal relations, not
merely counselling and care related to reproduction and sexually transmitted
diseases. It refers to the integration of the somatic, emotional, intellectual and
social aspects of sexual being in ways that are positively enriching and that

enhance personality, communication and love.
Reproductive Rights embrace certain human rights that are already recognized
in national laws, international laws and international human rights documents and
other consensus documents. These rights rest on the recognition of the basic rights
of all couples and individuals to decide freely and responsibly the number, spacing
and timing of their children and to have the information and means to do so, and
the right to attain the highest standard of sexual and reproductive health. It also
includes the right to make decisions concerning reproduction free of
discrimination, coercion and violence, as expressed in human rights documents.
Sexual and reproductive rights are the right of every individual to:
• Reproductive decision-making, including the choice to marry and determine the
number, timing and spacing of their children.
• Sexual and reproductive security, including freedom from sexual violence and
coercion.
• Be informed and have access to safe, effective, affordable and acceptable methods
of family planning of their choice. This includes other methods of their choosing
for regulating their fertility which are not against the law.
• Have 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.
• Information and the means needed to exercise these choices
Reproductive health is central to the 2030 Agenda
The 2030 Agenda for Sustainable Development contains a number of
targets related to reproductive health. Specifically,
Target 3.7 calls for ensuring universal access to sexual and reproductive health-
care services, including family planning, information and education, and the
integration of reproductive health into national strategies and programs by 2030.

Target 5.6 calls for ensuring universal access to sexual and reproductive health
and reproductive rights
Target 3.1: Reducing the global maternal mortality ratio to less than 70 per
100,000 live births
Target 3.2: Ending preventable deaths of newborns and children under 5 years of
age.
Target 5.3: Eliminating all harmful practices, such as child, early and forced
marriage and female genital mutilation.
Access to health care providers, services and health information
An important international instrument is the convention on the elimination
of all forms of discrimination against women which obligates the states parties to
ensure “access to health care services, including those related to family
planning” and mentions appropriate services in connection with pregnancy and
the right to decide on the number and spacing of children.
Egypt had reached the stage of developing an extensive basic health service
delivery network: over 95 % of the population lived within 5 kilometers of a
health facility. Nevertheless, women’s use of the services was still at a low level,
especially in the underprivileged southern part of the country (Upper Egypt, as
the located upstream of the Nile River). Even though the health service provision,
or the geographical access, is improved, local women may not use the services
unless the provided services meet their demands in quality and cultural manners.
In other words, demand-side barriers are as important as supply-side factors in
deterring people from obtaining appropriate health services among vulnerable
groups of population including rural women.

Barriers to Accessing Health Care Services:-
❖ Shortages of general practitioners, specialist medical services, Aboriginal
health workers, and a range of other health services particularly in rural
areas.
❖ A lack of affordable health care services.
❖ A lack of awareness of existing services.
❖ Health services being ill equipped to deal with the complexity of the health,
social, emotional wellbeing, cultural needs of women and lack of culturally
appropriate services and information.
❖ Feelings of shame and embarrassment in the area of reproductive and
sexual health (criticism from others, lack of communication).
❖ Distance to health care services and lack of affordable transport,
particularly in rural and remote areas.
❖ Poverty is a major barrier to accessing services and treatment in many
countries.
❖ Sexual health services have generally been neglected because providing
them requires governments to acknowledge sexual rights including sexual
pleasure and sexual orientation; and address issues such as gender roles and
power imbalances within relationships.
❖ Lack of health insurance.
Global perspective on women’s health
Global Health has been defined as the ‘area for study, research and
practice that places a priority on improving health and achieving health equity for
all people worldwide.
Global women’s health focuses primarily on obstetric and gynecologic
issues including family planning, pregnancy, delivery, sexually transmitted
diseases, gynecologic diseases and cancers, menopause, as well as infectious and
non-communicable diseases (NCD) in resource-poor settings.

1-Maternal mortality
Almost 800 women die per day from pregnancy related causes worldwide.
Maternal mortality rates in developed nations (16 per 100,000 births) are much
lower than in resource-poor countries, where as many as 1,000 women die per
100,000 births.
Causes of Maternal Mortality
Direct causes of death
▪ Thrombosis and thromboembolism
▪ Antepartum hemorrhage and postpartum hemorrhage
▪ Amniotic fluid embolism
▪ Genital tract sepsis
▪ Early pregnancy/ectopic pregnancy
▪ Pre-eclampsia and eclampsia
▪ Anaesthesia
Indirect causes of death
▪ Cardiac
▪ Indirect sepsis - influenza, pneumonia/others
▪ Indirect neurological conditions, including epilepsy
▪ Psychiatric
▪ Late maternal deaths.
2-Access to reproductive health services
Access to reproductive health care and related services remains sparse in many
parts of the world. Prenatal care may not be available or accessible. In developing
countries, the percentage of pregnant women who do not have access to or contact with
skilled health personnel prior to delivery is estimated at 20%.21 Further, "less than two
thirds (62%) of women in developing countries receive assistance from a skilled health
worker when giving birth." In developed nations, by contrast, skilled health workers
attend 99% of deliveries.

3-Family planning services
Data indicate increasing access to family planning services in many
countries. Indeed, the United Nations' 2008 Millennium Development Goals
Report suggests that the "unmet need for family planning has declined in most
countries." This means that women in these countries who wish to delay or avoid
having children increasingly have access to contraception. Nevertheless, access
to contraceptives remains limited in many parts of the world. The United Nations
Population Fund (UNFPA) estimates that 200 million women worldwide "want
to delay or prevent pregnancy but are not using effective contraception"
Limitations on access to contraceptives.
4- Access to abortion services
Abortion services varies significantly in different countries, ranging from
complete prohibition of the practice to pregnancy termination on demand. Unsafe
abortions are performed an estimated 20 million times per year in the least
developed countries, resulting in an estimated 68,000 maternal deaths. In addition,
thousands of pregnant women face health complications resulting from unsafe
abortions.
The health consequences to a woman from an unsafe abortion can be
severe depending on the method of induced abortion used and may include sepsis,
hemorrhage, trauma to reproductive organs, or even death.
5-Obstetric fistula
Obstetric fistulas (OF), sometimes called the ‘ near miss ’of maternal
mortality, are quite rare in developed nations, but in resource-poor nations over 2
million women are now living with OF, and about 100,000 new cases occur every
year. The highest incidence is in Africa and parts of Asia. As many as 10 – 20
million women will experience childbirth complications resulting in vesico- or
recto vaginal fistulas and subsequent infertility
The main contributors to OF are an immature pelvis (usually among

adolescents), first pregnancy, malnourishment, and minimal or no access to a
surgical facility according to the United Nations Population Fund, the main causes
of are ‘the three delays’: delay in seeking medical attention, delay in reaching a
medical facility, and the delay in receiving medical care upon arrival at the
medical facility
6-Female genital cutting
Female genital cutting (FGC) is defined as ‘all procedures involving partial
or total removal of the external female genitalia or other injury to the female
genital organs whether for cultural or other non-therapeutic reasons’.
According to the World Health Organization (WHO), more than 130
million women worldwide have undergone FGC, primarily in parts of Africa and
Asia.
The World Health Organization categorized FGC into four types
Type I: Involves removing part or the entire clitoris.
Type II: Includes removing part or all of the clitoris and labia minora and/or
majora.
Type III (the most severe): Involves removing all or part of the external genitalia,
including suturing the remnant tissue over the urethra and introitus (known as
infibulation); a small hole on the infibulated scar is left open for urination and
menses.
Type IV: Is the mildest and includes pricking, piercing, cutting, scraping, or
burning the genitalia. Immediate impacts on health include hemorrhage, infection,
sepsis, and even death.
Long-term complications include
1- Dyspareunia, dysmenorrheal, vaginitis, and cystitis.
2- Labor and delivery become more difficult,
3- Person is needed to defibulate (open the scar) prior to pregnancy (to prevent
dyspareunia).
Educating and empowering girls, women, families, and religious leaders about the

health and human rights issues surrounding FGC has been an effective means of
stopping this practice.
7-Child Marriage
Child marriage is marriage under the age of 18, is an ancient custom worldwide.
Factors that perpetuate child marriages include ensuring the girl’s financial
future, dowry, reinforcing social ties, and ensuring social status. Child marriage
is also seen as protective against premarital sexual activity, unintended
pregnancies, and sexually transmitted diseases (STDs) –an even greater concern
in this era of HIV/AIDS.
Impact of child marriage on a girl’s life and health
▪ Less formal education.
▪ Higher risk of sexually transmitted infections such as HIV and human
papilloma virus (husbands have had prior sexual partners), malaria.
▪ Early pregnancy, death during childbirth and obstetric fistula.
▪ Their offspring are at increased risk of premature birth and neonatal, infant,
and child death.
Government and non-governmental policies and programs must educate
the community, raise awareness, engage local and religious leaders, involve
parents, and empower girls through education and employment in order to stop
child marriages.

References
• Alexander, L. (2019). New Dimensions in Women’s Health. Seventh
Edition, chapter one.
• Alobo, G., Reverzani, C., Sarno, L., Giordani, B., & Greco, L. (2022).
Estimating the Risk of Maternal Death at Admission: A Predictive Model
from a 5-Year Case Reference Study in Northern Uganda. Obstetrics and
Gynecology International, 2022.
• Ashipala, D. O., & Mutsindikwa, T. (2022). Factors contributing to home
deliveries by women attending post-natal care at a selected clinic in Rundu
District, Kavango East Region, Namibia. Journal of Public Health in
Africa, 13(3).
• Chiang C., Elshair H., Kawaguchi L., Fouad A., Abdou M., Higuchi M., El
Banna R., Aoyama A., (2020). Improvements in the status of women and
increased use of maternal health services in rural Egypt. Nagoya J Med Sci,
74: 233–240. [PubMed].
• El Gelany s., (2020). Perceived barriers to accessing sexual and
reproductive health services among educated young women in Egypt ISSN:
2161-0932.

Pregnancy
Under supervision
Assist.prof. Amal Ahmed Yousef
Assistant professor of Woman’s Health & Midwifery Nursing Department,
Faculty of Nursing, Mansoura University
Prepared by
Amany Samy Elsayed Shahba
2023
Mansoura University
Faculty of Nursing
2022-2023
Department

▪ Introduction
▪ Definition of conception, pregnancy.
▪ Confirming pregnancy
▪ Hormonal changes during pregnancy.
▪ Fetal development during pregnancy.
▪ Common complications of pregnancy.
▪ References

General Objectives
At the end of this lecture each participant will be able to acquire knowledge
about women with Pregnancy.
Specific Objectives
At the end of this lecture the participants will be able to: -
✓ Define Conception, pregnancy.
✓ Confirm pregnancy
✓ Describe hormonal changes during pregnancy.
✓ Discuss fetal development during pregnancy.
✓ Explain common complications of pregnancy.

Introduction
Pregnancy is the term used to describe the period in which a fetus develops inside
a woman's womb or uterus. Pregnancy usually lasts about 40 weeks, or just over
9 months, as measured from the last menstrual period to delivery. Pregnancy lasts
an average of 266 days from the time of fertilization or 280 days from the first
day of the last menstrual period (often referred to as LMP). The gestational period
is divided into three phases or trimesters of approximately 3 months each. Not all
women have 28-day menstrual cycles, so due dates cannot be precisely
determined.
Definition of Pregnancy
Pregnancy is the period from conception to birth. After
the egg is fertilized by a sperm and then implanted in the lining of the uterus, it
develops into the placenta and embryo, and later into a fetus. Health care
providers refer to three segments of pregnancy, called trimesters. The major
events in each trimester are described below.
➢ First Trimester (Week 1 to Week 12)
➢ Second Trimester (Week 13 to Week 28)
➢ Third Trimester (Week 29 to Week 40)
Definition of Conception, also known as fertilization, is the union of the male
sperm cell and the female egg cell.
Confirming Pregnancy
Confirming a pregnancy involves a pregnancy test and a pelvic examination.
Human chorionic gonadotropin (hCG), a hormone specific to pregnancy, is
easily detectable in blood and urine throughout the first 3 months of pregnancy.

An hCG level of less than 5 mIU/mL is considered negative for
pregnancy, and anything above 25 mIU/mL is considered positive for
pregnancy.
➢ An hCG level between 6 and 24 mIU/mL is considered a grey area, and
you’ll likely need to be retested to see if your levels rise to confirm a
pregnancy.
➢ The hCG hormone is measured in milli-international units per milliliter
(mIU/mL).
➢ A transvaginal ultrasound should be able to show at least a gestational sac
once the hCG levels have reached between 1,000 – 2,000 mIU/mL.
➢ a diagnosis should not be made by ultrasound findings until the hCG level
has reached at least 2,000 mIU/mL.
➢ There are two common types of hCG tests. A qualitative test detects if hCG
is present in the blood. A quantitative test (or beta) measures the amount of
hCG actually present in the blood.
➢ Typically, the hCG levels will double every 72 hours. The level will reach
its peak in the first 8-11 weeks of pregnancy and then will decline and
level off for the remainder of the pregnancy.
➢ (Levels can first be detected by a blood test about 11 days after
conception and about 12-14 days after conception by a urine test.. The hCG
level usually reaches its peak between the second and third months of
pregnancy and then drops.
➢ A low hCG level can indicate:
• Miscalculation of pregnancy dating
• Possible miscarriage or blighted ovum
• Ectopic pregnancy

➢ A high level of hCG can also mean a number of things and should be
rechecked within 48-72 hours to evaluate changes in the level. A high
level can indicate:
• Miscalculation of pregnancy dating
• Molar pregnancy
• Multiple pregnancies
• You are taking fertility drugs.4a false positive
Hormonal Changes during Pregnancy:
▪ The secretion of certain hormones involved in ovulation, such as follicle-
stimulating hormone (FSH) and luteinizing hormone (LH), produced by the
anterior pituitary gland is suppressed throughout pregnancy.
▪ Shortly after implantation, specific cells in the outer portion of the developing
embryo secrete HCG, (a pregnancy-specific hormone).
▪ The body produces large amounts of HCG during the first trimester to
stimulate the corpus luteum, a structure formed on the wall of the ovary that
secretes estrogen and progesterone to prepare the body for pregnancy. The
corpus luteum is essential for the maintenance of early pregnancy. If it
regresses, a spontaneous abortion, or miscarriage, results.
▪ After the first 3 months of pregnancy, the corpus luteum is no longer
essential to maintain the pregnancy and HCG levels drop off. This change
occurs because the placenta begins producing large amounts of estrogen and
progesterone.
▪ The fetus also plays a role in maintaining the pregnancy. The fetal adrenal
glands produce a precursor hormone during the first 3 months of pregnancy
that is converted to estrogen in the placenta.

▪ The growing fetus and placenta contribute increasing quantities of estrogen
and progesterone to the maternal blood system as the pregnancy progresses;
the levels of both hormones rapidly decline at birth.
▪ Estrogen helps to regulate progesterone, thereby protecting the pregnancy,
and initiates one of the major processes of fetal maturation; without estrogen,
fetal lungs, liver, and other organs and tissues cannot mature.
▪ Estrogen also promotes the growth of ducts in the breast to prepare for
lactation. Progesterone suppresses uterine contractions during pregnancy and
stimulates the alveoli of the breasts.
▪ Another hormone unique to pregnancy is human placental lactogen (HPL),
also called human chorionic somatomammotropin. The structure and function
of HPL are similar to that of human growth hormone. HPL modifies the
metabolic state of the mother during pregnancy to facilitate the energy supply
of the fetus.
▪ HPL is also believed to stimulate breast growth during pregnancy and to
prepare the breasts for lactation. HPL levels rise throughout pregnancy. As
birth approaches, the levels decline.
Physical and Emotional Symptoms:
I. During the first trimester
▪ Enlarged and tender breasts
▪ Nausea and vomiting (commonly referred to as morning sickness).
▪ Women also may experience extreme fatigue.
▪ Decreased interest in sex, moodiness and irritability.
▪ Happiness and anxiety about a new pregnancy, or feeling upset about
an unplanned pregnancy.
▪ Skin changes such as darkening of the nipple and areola.

▪ woman gain 2 to 4 pounds (1 to 2 kilograms) during the first
trimester, and then 1 pound (0.5 kilogram) a week for the rest of the
pregnancy
II. During the second and third trimester.
▪ Morning sickness usually subsides, emotions even out and both energy
and sex drive usually return.
▪ Most women between 25 and 35 pounds (11.5 to 16
kilograms) during pregnancy. Shortness of breath, due to pressure of
the uterus and fetus on the bottom of the rib cage.
▪ Backache, caused by changes in posture to accommodate the growing
fetus.
▪ Some women experience muscle and leg cramps, numbness and tingling
of the hands, swollen or bleeding gums.
▪ Braxton–Hicks contractions (false labor). Swelling of the feet, ankles,
and hands is common and is caused by the increased weight of the uterus
slowing down blood and fluid circulation.
▪ Some women experience gastro-intestinal problems such as heartburn,
gas, and constipation.
▪ Skin changes can also occur. Striae-gravidarum (known as stretch
marks) begin to appear on the abdomen, breasts, and thighs; varicose
veins may appear in the legs; and chloasma (brown patches on the face
or neck) and linea nigra (a dark line from the belly to the pubic area),
both caused by increases in melanocyte stimulating hormone, may
occur. Changes in estrogen levels may cause redness of palms and red
spots on the upper body.

Fetal Development
Major changes occur with the developing embryo as:
➢ Within 24 hours after fertilization, the egg that will become your baby
rapidly divides into many cells. By the eighth week of pregnancy, your
baby will change names from an embryo to a fetus.
➢ The start of pregnancy is actually the first day of your last menstrual period.
This is called the gestational age, or menstrual age. It’s about two weeks
ahead of when conception actually occurs.
➢ Fetal development. It is measured in weeks. This means that during weeks
1 and 2 of pregnancy, a woman is not yet pregnant
• A full-term pregnancy is 40 weeks, or 280 days.
• One ounce equal 28 gm.one pound equal 450 gm,1cm equal 10 mm
• The last few weeks of pregnancy are divided into the following groups:
• Early term: 37 weeks through 38 weeks.
• Full term: 39 weeks through 40 weeks.
• Late term: 41 weeks through 41 weeks.
• Post term: 42 weeks and on.
• First Month The embryo grows to (8mm) in length and (4gm) in weight.
Foundations form for the nervous system, genitourinary system, circulatory
system, digestive system, skin, bones leg buds start to appear. The heart
beat appears on the 25th day. Rudiments, and lungs. The embryo has a two-
lobed brain and a spinal cord. The arm and the eyes, ears, and nose appear.
The head is disproportionately large because of the early brain
development.
• Second Month The embryo’s length is about (2.5cm), and it weighs about
(34 gm.). Ears, eyelids, fingers, and toes are distinct. At 8weeks, all the
major organs are formed. The circulatory system is closed, the neural tube
closes. After 8weeks, the embryo is called a fetus.

• Third Month The length of the fetus (5.4cm) and it weighs (58 gm.). The
sex of the fetus is defined, and it starts growing buds for future teeth, and
soft finger nails and toe nails. Kidneys begin to excrete urine. Other-organs
further develop. The nose and palate take shape, and the ears and earlobes
are developed. At this time, the fetal heartbeat can be heard with a Doppler
device.
• Fourth Month The fetal length is (18.5cm), and the weight is (146 gm.).
The mother will start to discern fetal movements. The fetus can hear, move,
kick, swim, sleep, and swallow. At this point, ultrasound can recognize
external genitalia. The skin is pink and transparent, and eye brows have
formed.
• Fifth Month Fetal length is (25.5 cm), and it may weigh (330 gm.). The
skin is loose and wrinkled. Vernix, a white, greasy substance, and lanugo,
a soft, fine hair, cover the skin for protection. Ultrasound can examine the
baby's
anatomy in detail.
• Sixth Month The fetus weighs about (670gm)-length (32cm). The skin is
red and eyelids remain sealed. The fetus becomes active by kicking,
punching, stretching, and turning over. It also coughs, hiccups, and
responds to sudden noise. If born, the infant will cry and breathe, and it can
survive with intensive neonatal care.
• Seventh Month The fetal length is about (37.5 cm), and it weighs about (
1200 gm.) The eyes open and close, and the fetus can suck its thumb. If
born, the infant can usually survive. Eyelids are open, and finger prints are
set.
• Eighth Month The fetus now will most likely settle into position for birth.
It is now about (43cm) and weighs (2kg). The face and body have a loose
and wrinkled appearance. Bones harden.

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