Sexual and Reproductive Health Package Research Paper

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The Five Core Aspects Of Sexual And Reproductive Health

The global WHO Reproductive Health Strategy (WHO Dept. of Reproductive Health and Research, 2004) defines the following five core aspects: improving antenatal, perinatal, postpartum, and newborn care; providing high-quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer, and other gynecological morbidities; and promoting sexual health.

Sexual And Reproductive Health: An Integrated Package

The different needs in sexual and reproductive health are not isolated from each other. They are simultaneous or consecutive related needs. People cannot be healthy if they have one element of the sexual and reproductive health package but are missing the others. Moreover, improvements in one element can result in potential improvements in other elements. Similarly, lack of improvement in one element can hinder progress in other elements.

Pelvic infection is a major cause for infertility worldwide. The resultant infertility is also the most difficult to treat. The magnitude of the problem of infertility will not be ameliorated except by a reduction of sexually transmitted infections, by safer births that avoid postpartum infection, and by decreasing the need for and the resort to unsafe abortion practices.

Infant and child survival, growth, and development cannot be improved without good maternity care. Proper planning of births, including adequate child spacing, is a basic ingredient of any child survival package. Unless adequately controlled, sexually transmitted infections, and in particular HIV infection, can impede further progress in child survival.

Family Planning

Family planning is a basic component of the sexual and reproductive health package. Fertility by choice, not by chance, is a basic requirement for women’s health. A woman who does not have the means to regulate and control her fertility cannot be considered in a ‘state of complete physical, mental and social well-being,’ the definition of health (shown previously) in the WHO constitution. She cannot have the joy of a pregnancy that is wanted, avoid the distress of a pregnancy that is unwanted, plan her life, pursue her education, undertake a productive career, and plan her births to take place at optimal times for childbearing, ensuring more safety for herself and better chances for her child’s survival and healthy growth and development. A woman with an unwanted pregnancy cannot be considered in good health, even if the pregnancy is not going to impair her physical health, and even if she delivers the unwanted child alive and with no physical disability.

Fertility regulation is a major element in any safe motherhood strategy. It reduces the number of unwanted pregnancies, with a resultant decrease in the total exposure to the risk as well as a decrease in the number of unsafe abortions. Proper planning of births can also decrease the number of high-risk pregnancies.

Family planning improves the quality of life not only for women, but also for the family as a whole and particularly for children. The quality of child care – including play and stimulation as well as health and education – inevitably rises as parents are able to invest more of their time, energy, and money in bringing up a smaller number of children.

In the sexual and reproductive health approach, family planning services are not ‘demographic posts.’ Women are not ‘targets’ for contraception, for which policymakers and administrators set ‘quota’ for services to accomplish. As the ICPD Programme of Action states, ‘‘Family planning programmes work best when they are part of or linked to broader reproductive health programmes that address closely related health needs’’ (UN, 1994: 33).

Integration Of Sexual And Reproductive Health Services

Related sexual and reproductive health interventions often come to be delivered over time as separate and discrete activities, rather than as a comprehensive response to people’s needs at different stages of their lives. For example, family planning clinics often function independently of those catering to other aspects of maternal and child health. A woman attending a clinic session for child immunization may not, at the same time, be able to obtain care for her own health needs; she will be asked to come back on a different day, or even to go to a different health facility.

The approach to integration should be pragmatic. Different situations in countries should be judged in their own context. There is much room for broadening the primary health-care package to include sexual and reproductive health interventions beyond the traditional maternal and child health approach. There is also a potential for expanding the range of services offered in community-based and clinic-based family planning services to include other selected specific interventions in sexual and reproductive health care. Specific elements in the strategy for prevention and control of sexually transmitted infections can be incorporated in maternal and child health (including prenatal care) and family planning services. The guiding principle is that no opportunity should be missed, where a capacity exists, for meeting all sexual and reproductive health needs.

The need for comprehensive sexual and reproductive health care should not translate into an all-or-none situation. Providing people with some elements of the service is better than providing no services. Services could be built up as resources become available and according to level of need and demand. Nor should integration result in dilution of available resources. Rather, it should result in more effective use of resources.

Implementation Of The Sexual And Reproductive Health Package

Components in the sexual and reproductive health package pose different challenges in implementation (Fathalla, 2002).

One part of the package includes traditional services with which we already have experience. These include maternal and child health services and family planning. The challenge will be how to expand the coverage and improve the quality of the services.

In other parts of the package, we are challenged to meet sensitive and emerging needs. These include the pandemics of sexually transmitted infections and HIV, the tragedy of unsafe abortion, and gender-based violence and sexual abuse in all its offensive forms. The challenge here is how to approach these sensitive and socially divisive issues, how to overcome deep-rooted traditions and social barriers, and how to influence human behavior.

In another part of the package, we are challenged to serve new customers. Among the new customers we need to reach and serve are adolescents, men, and the growing number of displaced persons and refugees. Services, including information and education, need to be tailored to serve the needs of these new customers. The biggest ever generation of young people between 15 and 24 years is rapidly expanding in many countries and their special needs have to be met. The long-neglected sexual and reproductive health needs of refugees are now being increasingly recognized.

Another part of the package includes services needed that are less affordable. These include treatment of HIVpositive pregnant women to prevent transmission of the infection to the fetus and newborn; infertility management; and detection and management of reproductive cancers. The challenge is to develop and test new, cost-effective interventions that can be implemented in resource-poor settings.

The appropriate balance in the sexual and reproductive health package can only be designed and developed at the national level. Each country needs to identify problems, set priorities, and formulate its own strategies in light of its needs and capacities.

Special Considerations Of Sexual And Reproductive Health Care

Sexual and reproductive health care is a part of general health care. There are, however, different considerations and challenges. Sexual and reproductive health-care providers deal with mostly healthy people. They often have to consider the interests of more than one ‘client’ at the same time. They deal mostly with women. And they have to deal and interact with society. These special considerations have ethical, legal, and human rights implications.

Dealing With Healthy People

Sexual and reproductive health-care providers respond to needs of healthy subjects, related to their physiological, sexual, and reproductive functions (including the prevention of unwanted pregnancy and the prevention of sexually transmitted infections). Sexual and reproductive health care is more health-oriented than disease-oriented. Promotive and preventive health care are major components of sexual and reproductive health care.

Dealing with healthy people implies a change in the provider–patient relationship, from a giver–recipient relationship to a more participatory type of health care. Counseling is the description for a good part of sexual and reproductive health care. There is no other field of medicine in which participation of the patients in healthcare decisions is that necessary. The general ethical principles of respect and autonomy dictate that patients are required to give their informed consent to the treatment proposed by the health-care provider, freely and without undue pressure or inducement. In the case of sexual and reproductive health care, clients have to make informed choices and decisions.

The risk/benefit ratio is different when a drug or device is used for a healthy subject, to prevent a condition that may or may not happen, from what it is when a drug or device is used by a person suffering from a disease that in itself carries a risk. The risk/benefit ratio is also different from another aspect. Often, very large numbers of people are involved, so that rare, adverse effects assume more importance. Safety and efficacy of drugs and devices are regulated by government agencies, and are subject to laws of product liability. Sexual and reproductive health products, and particularly contraceptives, are recognized as different from products developed and marketed to treat patients who have disease conditions.

In dealing with healthy people, the temptation to overmedicate for normal life events would be resented, but in sexual and reproductive health care of women, and particularly in maternity care, it has often been accepted, sometimes without valid scientific evidence, by the health profession. A WHO report cites four such interventions as particularly subject to overuse: cesarean section, routine episiotomy, routine early amniotomy, and abuse of oxytocin (WHO, 2005).

Dealing With More Than One Client

Different from other health professionals, sexual and reproductive health-care providers often deal with, or have to consider, more than one client at the same time. This other party to a management decision could be a woman’s male partner, or her fetus. The interests of the different parties may coincide and may diverge, or even conflict. The ethical principles of beneficence and nonmaleficence, to do good and to do no harm, pose a challenge when, for example, the interest of the mother conflicts with the interest of the fetus.

Dealing Mostly With Women

Providers of sexual and reproductive health care deal mostly with women, who in many societies are still subordinated and undervalued. Apart from respecting women and treating them as equals, providers must also be sensitive to their concerns and perceptions. Respect for women should be shown in providing them with confidentiality, privacy, and access to all information they need to make well-informed decisions about their health. Health-care professionals in developing countries know that even though the majority of women in many parts of the world are illiterate this does not mean that they are not fully capable of making sound decisions. Poor people have a very narrow safety margin for error in making decisions about their lives and, consciously or subconsciously, they know that. Women, literate or illiterate, rich or poor, given the information and the right to choose and decide, will make the right decisions for themselves and their families.

Lack of respect for confidentiality for women seeking sexual and reproductive health care can deter them from seeking advice and treatment and thereby adversely affect their health and well-being. Women will be less willing, for the reason of unreliable confidentiality, to seek health care for diseases of the genital tract, for contraception, or for incomplete abortion, and in cases where they have suffered sexual or physical violence.

Women have been excluded from historical sources of moral authority, and are still underrepresented in learned professions of medicine and law, and in legislative assemblies. The voices of women, and their perspectives, often have not been taken into consideration in laws, policies, and regulations governing sexual and reproductive health care for women.

Dealing With Society

No society, no culture, no religion, and no legal code has been neutral about sexual and reproductive life. No other health profession has to deal with such emotionally charged health issues as sexuality and abortion. As new health technologies develop, for example, in the area of infertility management, new issues arise for which society may not be well prepared. Enforcing perceived interests of the society may violate women’s sexual and reproductive health rights.

International Commitment To Sexual And Reproductive Health

Sexual And Reproductive Health And The Millennium Development Goals (Mdgs)

The Millennium Development Goals (MDGs), which grew out of the United Nations Millennium Declaration adopted by 189 Member States in 2000, provide the new international framework for measuring progress toward sustaining development and eliminating poverty (UN Millennium Project, 2005). Although there was no specific goal about sexual and reproductive health, out of the eight MDGs, three – improve maternal health, reduce child mortality, and combat HIV/AIDS, malaria, and other diseases – are directly related to sexual and reproductive health. Specific targets under these goals are to reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio; to reduce by two-thirds, between 1990 and 2015, the underfive mortality rate; and to have halted by 2015, and begun to reverse, the spread of HIV/AIDS. Moreover, at the 2005

World Summit review of the MDGs at the United Nations, world leaders committed themselves to ‘‘achieving universal access to reproductive health by 2015, as set out at the ICPD, integrating this goal in strategies to attain the internationally agreed development goals, including those contained in the Millennium Declaration’’ (UN, 2005: 16).

WHO Reproductive Health Strategy To Accelerate Progress Toward The Attainment Of Mdgs

A reproductive health strategy to accelerate progress toward the attainment of MDGs was adopted by the 57th World Health Assembly in May 2004. The guiding principles for the strategy are the internationally agreed instruments and global consensus declarations on human rights (WHO Dept. of Reproductive Health and Research, 2004).

The strategy recognizes that each country needs to identify problems, set priorities, and formulate its own strategies for accelerated action through consultative processes involving all stakeholders. Five overarching activities are identified: strengthening health systems capacity; improving information for priority setting; mobilizing political will; creating supportive legislative and regulatory frameworks; and strengthening monitoring, evaluation, and accountability. A framework for implementing the WHO Reproductive Health Strategy was also developed (WHO Dept. of Reproductive Health and Research, 2006b).

Conclusion

A global overview of sexual and reproductive health provides reasons for public health, development, and human rights concern. Improving the situation, alleviating the burden, and addressing the glaring inequity have been on the international and national agendas for many years now. Although progress has been made, it has been uneven, and major parts of the world still fall short of desired goals. The know-how is available. Cost-effective interventions are affordable. A sustained collaborative effort supported by political commitment, together with mobilization and rational allocation of resources, can bring about a brighter future for sexual and reproductive health.

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