Chapter One - RH For Africa Medical College - MPH

Africa medical college
School of public health
Reproductive and Sexual Health

Chapter one:
Introduction to reproductive health
Objectives
At the end of this session the participants will be
able to:
Familiar with the basic concepts of Reproductive Health

Describe the history of RH and the reasons behind the shift from
MCH to RH
Describe the role of reproductive health on achieving UHC
List the components of RH
3
Definition of Reproductive Health
Health
“A state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity” (WHO 1948).
Reproductive health
A state of complete physical, mental and social well being and
not merely the absence of disease or infirmity, in all matters
relating to the reproductive system and to its functions and
process (ICPD 1994)
4
Cont’d….definition
Cont’d ……definition
The definition of reproductive health by ICPD implies that:
People are able to have a :
 Satisfying and safe sex life,
 Capability to reproduce and
 Freedom to decide if, when and how often to do so.
The rights of men and women to;

 Be informed and
 Have access to safe, effective, affordable and acceptable methods of family
planning of their choices, for regulation of fertility which are not against
the law.
 Men and women have the right to access 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.
 Reproductive health is a universal concern
Special importance for women particularly during the
reproductive years.
Men too have reproductive health concerns and needs
 Reproductive health is life-long goal
Beginning even before women and men attain sexual maturity and
continuing beyond a woman's child-bearing years.
 Individual RH needs differ at each stage of life = life-

cycle approach to address the needs
 An inability to address RH concerns may result in future
health complications
RH status may reflect cumulative effects and
experiences that occurred in earlier life phases
8
Reproductive health care
“The constellation of methods, techniques and services that
contribute to reproductive, sexual health and wellbeing by
preventing and solving reproductive health problems.
It also includes 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”.
(F Roudi-Fahimi, L Ashford , 2008)
Historical development of RH
Ancient time (Hippocrates &
Galen).
Less than 50% of the babies
survived to adulthood.
This led families to have as

many children as possible.
The need for special attention

for children was noted in the
early days of medicine by
Hippocrates (400 – 375 BC).
History… Ancient time …
 Hippocrates described the
conditions found in small
babies.
 Galen (130 – 200 AD)

wrote about the importance
of cleanliness, salting and
swaddling.
Latter part of 19th C and early 20th C
 The idea of a public responsibility to provide services for
mothers and children became current.
 Parallel developments in three areas:

Increasing social action for welfare of children,
Advances in medicine and
Developments of local and state health departments.
Eg. US & Europe MCH became integral part of health care
and Financed by the state government.
12
During mid and 2nd half of 20th C
 At establishment of WHO in 1948, MCH was one of the four
priorities health issues
(Tuberculosis, Malaria, MCH & Venereal Diseases).

 Each Medical Head quarter included a medical deputy director
for MCH
 More International commitment for child survival
UNICEF introduced GOBI-FFF
 Growth monitoring, oral rehydration, breast-feeding and

immunization--female education, family spacing and food
supplementation (GOBI-FFF).
13
… 2nd half of 20th C …
In 1960s:
Impact of rapid Population growth becomes an agenda
“Population bomb”
Establishment of UNFPA and availability of technology for

fertility regulation including introduction of Pills & IUDs.
Emphasis to expand Family Planning (FP) especially in poor

countries
14
 During 1970s & 1980s,
Governments developed population policies supported by UN
MCH - essential component of PHC at Alma ata
Declaration,1978
The neglected tragedy of maternal death got attention. The
question Where is the “M” in MCH? was raised in Lancet in
1985.
 Safe Motherhood Conference held in 1987, in Nairobi, Kenya,
◦ Aimed to reduce the number of deaths and illnesses associated
with pregnancy and childbirth.
15
 During 1990s
◦ International Conferences on population and
Development conducted (ICPD 1994 in Cairo)
◦ The Paradigm Shift from MCH to RH
16
 Three important elements behind the paradigm shift:
1. Recognition of the needs of people in sexuality and reproduction
beyond fertility regulation.
2. The articulation and interpretation of the international human
rights treaties in terms of reproductive and sexual health
3. The advent of the HIV/AIDS pandemic
 The shift was as a result of contribution of women's movement,

International community and International human Right conventions
17
 ICPD ,1994 put an end to the idea of conventional policy of
suppressing population increase that was based only on the
macro-perspective of “population increase inhibits economic
development.”
 The aim of ICPD was to enhance reproductive health and

promote reproductive rights rather than population policies
and fertility control
18
 The Cairo conference enlarged the scope of policy
discussions.
◦ The emphasis of population policies shifted away from
slowing population growth to improving the lives of
individuals, particularly women
◦ It argues that it is possible to achieve the stabilization of
world population growth, while attending to people’s
health needs and respecting their rights in reproduction.

19
 The ICPD draws a clear connection between reproductive
health, human rights and sustainable development.
When SRH needs are not met, individuals are deprived of

the right to make crucial choices about their own bodies and
futures, with a cascading impact on their families’ welfare
and future generations
20
 The ICPD, Cairo, 1994 broke new ground in endorsing

men’s involvement in SRH, a realm that until then had
overlooked their active role.
21
…2 nd
half of 20 C … th
 Beijing Conference- the 4th World Conference on Women

held in Beijing in 1995, reproductive rights were clearly stated
as a part of women’s human rights, and equal relationship,
agreement and joint responsibility between men and women
regarding sex and reproduction were widely recognized
22
ICPD AND MDGs
The ICPD POA demands addressing of the following by year
2015:
Universal access to RH services including FP and sexual
health,
Drastic reduction in Infant and maternal mortality
Wide range of measures to ensure equality between men and
women and empowerment of women,
Universal access to elementary education,
Correction of the “gap between men and women” in
education.
23
Cont’d…. ICPD AND MDGs
 ICPD held in Cairo in 1994, presented a Program of Action
(PoA).
 To achieve the goal of universal access to reproductive health
(RH) services for every one in all countries till 2015.
 Five years later in1999, a review of ICPD-PoA, known as
ICPD+5 revealed (IDGs) into the Millennium Development
goals (MDGs) took place.
 UN World Summit (2005)in New York endorsed incorporating
universal access to reproductive health into the MDGs.
 A comprehensive review of ICPD at the mid point to 2015

was recognized in 2004 as ICPD+10, which yet again
discovered many countries lagging behind in RH indicator nor
they are anyway near to the progress demonstrated in
developing regions of the world.
 The key goals which were embedded in the ICPD-PoA
were:
By 2005;
 60% of primary health care and family planning facilities
should offer;
◦ The widest achievable range of safe and effective family planning
methods,
◦ Essential obstetric care, prevention and management of
reproductive tract infections, including sexually transmitted
infections (STIs), and barrier methods to prevent infection;
 80% of facilities should offer such services by 2010, and
2015.
 Skilled attendants should assist at least 40% of all
births where the maternal mortality rate is very high;
and 80% globally by 2005.
 This coverage should be 50% and 85% by 2010; and

60% and 90% by 2015.
 The gap between the proportion of individuals using

contraceptives and the proportion expressing a desire
to space or limit their families should be reduced by
half by 2005, by 75% by 2010, and by 100% by 2015.
MDGs AND SDGs
 MDGs come to its termination by 2015
 Global leaders from 193 countries held summit at
new York on Sept. 25-27, 2015 for envision the new
development agendas
 The new agenda is ‘’The 2030 agenda for sustainable

development” to guide the world for next 15 years.
(WHO, 2015; UNDP, 2015)

28
Cont’d……..MDGs AND SDGs
 SDGs was build on MDGs & comprised of 17 goals
and SDGs has 169 targets
 About 30 targets are Health & Health Related; of

which 13, HSGs and 17 OHRGs)
 SDGs Targets have 244 indictors (53 for Health; of

which 27 HSGs and 26 from OHRGs targets)
 SDGs are envision to address five Ps: people, planet,

prosperity, peace and partnership.
29
 SDGs are covering a wide range of human activity
across, three SD dimensions (economic, social and
environmental).
 Compared with the MDGs that comprised only 8
goals and 21 targets, the SDGs are supremely

ambitious and unprecedented in scope.
 Health is identified as a central place as a major

contributor to and beneficiary of sustainable
development policies.
(WHO, 2015)
30
 The UN-SDGs pointed out that regions/sub-
regions & countries would need to design
specific areas of focus, agendas & mechanisms to
achieve the goals.
 Based on this the African region composed of 5
Sub-regions and adopted 12 priority goals
 In the same way Ethiopia integrated SDGs within

the (GTPII) with Identified 10 priority areas.
(UNECA, 2015; FDRE, 2017).
31
Main objective of SDGs
1. To achieve integration/interlink between the
implementation of different goals
2. To cover five areas/5Ps: people, planet,

prosperity, peace and partnership
32
Summary global goals
Sexual and Reproductive Health Rights
 Sexual and reproductive health are integral elements
of the right of everyone;
 to the enjoyment of the highest attainable standard of
physical and mental health.
 Many obstacles stand between individuals and their
enjoyment to sexual and reproductive health.
 These obstacles are interrelated and entrenched, operating
at different levels:
 In clinical care,
 At the level of health systems, and
 In the underlying determinants of health.
Cont’d……
 In addition to biological factors, social, economic and
other conditions bear upon a woman’s sexual and
reproductive health.
 The Special Rapporteur -on “policy approach” to the
right to health, especially in relation to sexual and
reproductive health, and in poverty reduction (
E/CN.4/2004/49, 2004).
Maternal Mortality
 Many causes of maternal mortality are closely related
to a failure to realize the right to the highest attainable
standard of health.
 Properly integrated, the right to health can help ensure
that the relevant policies to address maternal mortality
are more equitable, sustainable and robust.
 The right to health also provides a powerful
campaigning tool in the struggle for a reduction in
maternal mortality.
Cont’d……
 In many countries, marginalized women, such as women
living in poverty, and ethnic minority or indigenous
women, are more vulnerable to maternal mortality.

 Maternal mortality and morbidity rates reveal sharp
discrepancies between men and women in their
enjoyment of sexual and reproductive health rights (
A/61/338, 2006).
Restrictions on Abortion
 The impact of criminal and other legal restrictions on abortion;
conduct during pregnancy; contraception and family planning; and
the provision of sexual and reproductive education and information.

 Some criminal and other legal restrictions in each of those areas,
which are often discriminatory in nature, violate the right to health
by restricting access to quality goods, services and information.

 Moreover, the application of such laws as a means to achieving
certain public health outcomes is often ineffective and
disproportionate (A/66/254, 2011).

Adolescence
 The nature of and challenges associated with sexual and reproductive
health rights in adolescence have also been examined by the mandate.

 Healthy sexual development requires not only physical maturation, but
an understanding of healthy sexual behaviours and a positive sense of
sexual well-being.
 Sexual initiation can be a natural and healthy aspect of adolescence,
and adolescents have the right to be provided with the tools and
information to navigate sex safely.

 Sexual activity among adolescents is widespread, although rates vary
significantly.
Cont’d…..
 Yet, adolescents around the world face significant discrimination and barriers in
accessing the information, services and goods needed to protect their sexual and
reproductive health, resulting in violations of their right to health.
 States should adopt a comprehensive gender-sensitive and non-discriminatory
sexual and reproductive health policy for all adolescents.
 They should integrate the policy into national strategies and programmes.
 The policy must be consistent with the human rights standards and recognize that
unequal access by adolescents constitutes discrimination (A/HRC/32/32, 2016).

Reproductive Health rights
Reproductive rights: are defined in the ICPD Programme of Action and
are based upon rights recognised in international human rights treaties,
declarations and other instruments, including,
 International Covenant on Economic, Social and Cultural Rights,

 International Covenant on Civil and Political Rights,
 UN Convention on the Elimination of All Forms of Discrimination Against
Women (CEDAW),
 UN Convention on the Rights of the Child, and International Convention on
the Elimination of all Forms of Racial Discrimination.

 Right to decide freely and responsibly the number and spacing of one’s
children and to have the information and means to do so.
 Right of women to have control over and decide freely and responsibly on
matters related to their sexuality, including sexual and reproductive health,
free of coercion, discrimination and violence.
 Right to liberty and security of person.
 Right to be free from torture, cruel, inhuman or degrading treatment.

 Right of men and women to marry only with their free and full consent
 Right to life and survival.
 Right to enjoy the benefits of scientific progress and its applications, and to
consent to experimentation.
 Right to privacy.
 Right to participation.
 Right of access to information.
 Right to education.
 Right to freedom from violence against women
 Right to the highest attainable standard of health.
 Right to freedom from discrimination (on the basis of sex, gender, marital
status, age, race and ethnicity, health status/disability).
Rationales of reproductive health rights
Providing reproductive health services is essential , because:

 Access to reproductive health care is right
 Morbidity and mortality related to the reproductive system is a
significant public health issues
 Timely provision of reproductive health services can prevent

disease and disability related to unwanted pregnancy, sexual and
other forms of gender-based violence, HIV infection and a range
of reproductive disorders.
Components of Reproductive health
A major breakthrough at the ICPD, reaffirmed repeatedly since, is that
these services are essential for all people, married and unmarried,
including adolescents and youth. For people to realize their reproductive
rights, the ICPD Programme of Action calls for and defines reproductive
and sexual health care in the context of primary health care to include;
(a) Family planning;
(b) Antenatal, safe delivery and post-natal care;
(c)Prevention and appropriate treatment of infertility;

Components of Reproductive health
(d) Prevention of abortion and management of the consequences of abortion;
(e) Treatment of reproductive tract infections;
(f) Prevention, care and treatment of STIs and HIV/ AIDS;
(g) Information, education and counselling, as appropriate, on human
sexuality and reproductive health;
(h) Prevention and surveillance of violence against women, care for survivors
of violence and other actions to eliminate traditional harmful practices, such
as FGM/C;
(i) Appropriate referrals for further diagnosis and management of the above.
Components of reproductive health care
 Reproductive health care is vital in preventing and solving

reproductive health related problems
◦ If the components are negatively implemented, it will cause
complications to reproductive health.
47
Reproductive health concerns
 Reproductive health is a crucial part of general health and a

central feature of human development.
 In most developing-country settings, much of the loss of life
and human productivity that is due to poor RH could be
prevented with affordable and cost-effective programs.
 However, a number of factors exist affecting the existence and
use of reproductive health services.
11/23/2023 48
Concerns……cont’d
Reproductive health can be affected by :
 The needs for reproductive health

 The health care system &
 Health seeking behavior & service utilization
11/23/2023 49
 Reproductive health affects the context of people's lives, including
◦ Economic circumstances
◦ Education
◦ Employment
◦ Living conditions
◦ Family environment
◦ Social and gender relationships and
◦ The traditional and legal structures
11/23/2023 50
 Sexual and reproductive behaviors are governed by complex
biological, cultural and psychosocial factors.
 Therefore, the attainment of reproductive health is not limited
to interventions by the health sector alone.
 The status of girls and women in society, and how they are
treated or mistreated, is a crucial determinant of their
reproductive health.
11/23/2023 51
Factors that affect reproductive health operate at several level:
 At Household and community
 At health system
 At the public polices and actions
11/23/2023 52
Concerns……cont’d @households concerns
Health behavior :-
 Avoiding or minimizing risks
 Using Family Planning methods
 Practicing safe sex
 Dietary habits
 Sanitary practices
 Utilization of health services
 Decision making process & control of resources
11/23/2023 53
Concerns……cont’d @ households
concerns
Household resources and assets
 Household income
 Access to information
 Quality of housing
 Education of household members
11/23/2023 54
Concerns……cont’d @ Community
concerns
 Gender norms and practices
 Existence of effective community groups & social cohesion
 Cultural and religions values
11/23/2023 55
Concerns……cont’d @ health system
 Quality : Availability of service, supplies and skilled
professionals
 Access: Physical and financial accessibility
 Referral for complications and emergencies
 Health information campaigns
 Logistic management system for family planning and other
commodities
11/23/2023 56
Concerns……cont’d @other related
 Transportation,
 Communications
 Education, and
 Water and sanitation.
 Agriculture
 Etc.
11/23/2023 57
Possible Solutions for RH concerns
Lifecycle approach to health

◦ Women’s right to the enjoyment of the highest standard of health must
be secured throughout the whole life cycle in equality with men
Women empowerment & right based approach to RH

◦ Good health is essential to leading a productive and fulfilling life, and
the right of all women to control all aspects of their health is basic to
their empowerment.
11/23/2023 58
Possible solution……cont’d
 Improve access & utilization of contraceptive methods

 Mobilizing and providing sufficient resources to meet the growing
demand for access to information, counseling, services and follow-up
on the widest possible range of safe, effective, affordable and
acceptable contraceptive methods
 Comprehensives post abortion care & safe abortion service
11/23/2023 59
 Providing Good quality RH services

Improving access to Essential obstetric care
Equipping the facility with skilled man power, equipments
& necessary supplies
Promoting good referral system
Etc
11/23/2023 60
 Making STIs and HIV/AIDS prevention and control an
integral component of reproductive and sexual health
programs
 Avoiding of all forms of VAW & care & support for victims
of VAW
 Avoiding all forms of harmful traditional practices.
 Good nutrition & Micronutrient supplementation for
mothers
11/23/2023 61
Right based approach
 Effectively addressing reproductive health problems calls for

an integrated, right-based approach that draws on the fields of
health, ethics, law and human rights.
 This approach can provide analytical tools to identify root
causes and inequity, shape humane and effective programs and
policies , and pressure governments into working proactively.
 A rights-based approach to sexual and reproductive health can
add momentum to policy-making and improvement of
services.
Right based approach
 Individuals have the right to control their sexual and
reproductive lives without interference,
 Governments must ensure equal access to health care,
including comprehensive reproductive health services.
 A right- based approach can provide health practitioners with
an ethnical framework and understanding of societal factors.
 It can improve the effectiveness of interventions and empower
clients.
Differences between a needs-based approach and a
rights-based approach
Needs-based approach Rights-based approach (RBA)
(NBA)
Vulnerability is Vulnerability is seen as a

Vulnerability addressed as a symptom structural issue, both
of poverty or caused by and leading to
marginalisation. unequal power relations in
society.
An increase in justice Justice is the focus of the
Justice may be achieved as a by- efforts. Thus it tends to
product of meeting challenge traditional, social,
needs, but it does not cultural and even legal
explore the injustices practices and norms that
that led to the may foster injustice.
Cont’d…..
Needs-based approach (NBA) Needs-based approach

Rights-based approach (RBA) (NBA) Rights-based
approach (RBA)
Tends to work with the Deals with the causes of

Discrimination symptoms of discrimination, discrimination, because it
(e.g. based on rather than causes. works with the power
gender, creed, imbalance between
caste, economy) authorities and vulnerable
groups that support such
discriminations.
Does not engage with the Focuses on addressing
Power relations issues around the power the differential power
imbalance between issues that underlie
authorities and vulnerable poverty and disadvantage
groups. In fact the latter are – and tries to re-draw the
likely to approach the current power equations.
power-holders for help, thus
Cont’d……..
Accountability In NBA projects, Works towards ensuring the

accountability is only in accountability of the state and
terms of outcomes – so other service-providers, and
that the funding agency push them to fulfil their
(governmental or non- obligations to respect the
governmental) is satisfied rights of all, especially of
that funds are used for marginalized people.
what was intended.
Citizenship Citizens are perceived as Citizens are seen as significant
beneficiaries who actors in a democratic state,
hopefully enjoy the and so emphasise opening up
largesse of the direct channels of
government. communication between
citizens (and other people
living within a state’s
Global goals & strategies of Reproductive health
 MDGs and RH
◦ were adopted in the 55th UN General Assembly in
September 2000 with the support of 149 heads of state
◦ Four of the eight development goals were directly related to
reproductive health
◦ There was progress in reducing child and maternal deaths
despite there are things to be done
67
Cont’d……global goal
 SDG and RH
◦ Has 17goals and 169 targets
◦ Goal 3: Ensure healthy lives and promote wellbeing for all
at all ages
 Target 3.8 Ensure universal accesses to sexual and
reproductive health for all
◦ The SDGs (after 10 years of MDG 5B) included target to
ensure universal access to SRH care and services by 2030
68
 SDG and RH
◦ Achieving sustainable development (SD) and eradication of

poverty requires taking into account population dynamics,
social, economic and cultural inequalities between men and
women, including with regard to the exercise of sexual and
reproductive health and rights.
69
 After 20 years of Cairo, we still have problems due to lack of

universal access to SRH:
◦ Differences in access to RH services by level of
development and socioeconomic status, between and within
countries;
◦ High levels of adolescent birth rates,
◦ Large number of women with unwanted fertility
◦ Unsafe abortion where legally banned
◦ High levels of maternal mortality
70
 UN Global Strategy for Women’s, Children’s and

Adolescents’ Health (2016-2030)
◦ Launched at the 70th session of the UN General Assembly in
Sep. 2015
◦ Three overarching objectives: survive, thrive and
transform
◦ is a roadmap to achieve right to the highest attainable
standard of health for all women, children and adolescents
–to transform the future and ensure every newborn, mother
71
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Africa medical college

School of public health

Reproductive and Sexual Health

Familiar with the basic concepts of Reproductive Health

 Capability to reproduce and

 Freedom to decide if, when and how often to do so.

The rights of men and women to;

 Have access to safe, effective, affordable and acceptable methods of family

 Individual RH needs differ at each stage of life = life-

It also includes sexual health, the purpose of which is the

This led families to have as

The need for special attention

 Galen (130 – 200 AD)

 Parallel developments in three areas:

priorities health issues

(Tuberculosis, Malaria, MCH & Venereal Diseases).

 Growth monitoring, oral rehydration, breast-feeding and

Establishment of UNFPA and availability of technology for

Emphasis to expand Family Planning (FP) especially in poor

◦ The Paradigm Shift from MCH to RH

 The shift was as a result of contribution of women's movement,

 The aim of ICPD was to enhance reproductive health and

slowing population growth to improving the lives of

individuals, particularly women

◦ It argues that it is possible to achieve the stabilization of

world population growth, while attending to people’s

health needs and respecting their rights in reproduction.

When SRH needs are not met, individuals are deprived of

 The ICPD, Cairo, 1994 broke new ground in endorsing

 Beijing Conference- the 4th World Conference on Women

 A comprehensive review of ICPD at the mid point to 2015

 This coverage should be 50% and 85% by 2010; and

 The gap between the proportion of individuals using

 The new agenda is ‘’The 2030 agenda for sustainable

(WHO, 2015; UNDP, 2015)

 About 30 targets are Health & Health Related; of

 SDGs Targets have 244 indictors (53 for Health; of

 SDGs are envision to address five Ps: people, planet,

goals and 21 targets, the SDGs are supremely

 Health is identified as a central place as a major

 In the same way Ethiopia integrated SDGs within

2. To cover five areas/5Ps: people, planet,

living in poverty, and ethnic minority or indigenous

women, are more vulnerable to maternal mortality.

discrepancies between men and women in their

enjoyment of sexual and reproductive health rights (

conduct during pregnancy; contraception and family planning; and

the provision of sexual and reproductive education and information.

which are often discriminatory in nature, violate the right to health

by restricting access to quality goods, services and information.

certain public health outcomes is often ineffective and

disproportionate (A/66/254, 2011).

health rights in adolescence have also been examined by the mandate.

an understanding of healthy sexual behaviours and a positive sense of

information to navigate sex safely.

reproductive health, resulting in violations of their right to health.

 States should adopt a comprehensive gender-sensitive and non-discriminatory

sexual and reproductive health policy for all adolescents.

unequal access by adolescents constitutes discrimination (A/HRC/32/32, 2016).