Reproductive Health Prof Biran Afandi

B iran A ffandi
Soegiharto Soebijanto
D epartment of Obstetrics & Gynecology

Faculty of M edicine , University of Indonesia
Jakarta
1
A ffandi B , Soebijanto S. Reproductive Health ,What is it ? Prepared for M odule of Reproduction ,Faculty of M edicine – University of Indonesia , 22 Oct 2007
Objectives:
1.To define Reproductive Health
2.To discuss the components
3.To overview magnitude of the
problems
4.To discuss ways of solution
2
‘The enjoyment of the highest
attainable standard of health is
one of the fundamental rights of
every human being without
distinction of race, religion,
political belief, economic or social
position’
Constitution of the World Health Organization
3
Reproductive Rights
 A ttaining the goals of sustainable, equitable
development requires that individuals are able
to exercise control over their sexual and
reproductive lives:
Reproductive health
Reproductive decision-making
Equality and equity for men and women
Sexual and reproductive security
Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990
4
‘Health is a state of complete
physical,
mental and social-being
and not merely the absence of
disease or infirmity’
Constitution of the World Health Organization
5
Definition of reproductive health
“Reproductive health is 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 processes.”
Lancet, 2006
6
Reproductive Health
A bility fertility
fertility regulation
sex
Success outcome of pregnancy

infant and child survival, growth and
development
Safety pregnancy and childbirth

fertility regulation
sex
7
Twelve pillars of reproductive health
The status of women
Family planning
M aternal care and safe motherhood
A bortion
Reproductive tract infections and HIV /A ID s
Infertility
Reproductive tract malignancies
Nutrition
Infant and child health
A dolescent reproductive health and sexuality
Sexual behaviour and harmful sexual practices
Environmental and occupational reproductive health
D iczfalusy. The Contraceptive Revolution - A n Era of Scientific & Social D evelopment, 1997
8
Traditional-practices
P ractice E xam ple
Beneficial breastfeeding
Neutral wearing of charms
Harmful female circumcision
9
Estimates of world population
2000 6
Population
Y ears (billions)
1987 5
0 0.2
Population in billions
1830 1.0
1930 2.0 1975 4
1960 3.0
1975 4.0
1987 5.0 1960 3
2000 6.0
1930 2
about 1830 1
AD
0 1650 1700 1750 1800 1850 1900 1950 2000 2010
Y ears
10
Estimates and projections of the population size in
the ten most populous countries of the world in
1995 and 2025
Population (million) Percentage
increase, or
Country 1995 2025
decrease
China 1222 1526 +25

India 936 1392 +49
United States 263 331 +26
Indonesia 198 276 +39
Brazil 162 230 +42
Russian Federation 147 139 -6
Pakistan 141 285 +102
Japan 125 122 -2
Bangladesh 120 196 +63
Nigeria 112 238 +113
UNFPA, 1995
11
Projected increase in the elderly population*
between 1990 and 2025; selected countries
Country Percentage increase
Indonesia 414
Thailand 337
India 242
China 220
B angladesh 219
A ustralia 137
United K ingdom 45
Sweden 33
Population aged 65 years and over
WHO, 1995a D iczfalusy. The Contraceptive Revolution - A n Era of Scientific & Social D evelopment, 1997
12
Rationales for Family Planning
13
14
 M aternal mortality rate by number of life births:
15
 Infant mortality by age of mother:
16
 Infant mortality by birth order:
17
Infant deaths per 1000 births among
babies born after different birth intervals
Birth interval (months)
Country < 24 24 - 47 48+
Egypt 203 97 55
Nepal 200 131 71
Bangladesh 185 89 58
Pakistan 183 103 71
Turkey 183 95 76
Indonesia 138 76 56
Peru 137 87 55
K enya 117 68 59
Nigeria 116 74 46
Sudan 98 60 37
World Fertility Survey (1984)
18
Estimated distribution of direct causes of 4
million neonatal deaths for the year 2000
Infections
36%
Lancet, 2005
19
Reproductive behavior
‘Too many, too close, too early, and too
late pregnancies are a major cause of
maternal, infant and childhood
mortality and morbidity’
M exico City D eclaration on Population and
D evelopment, A ugust 1984
20
Point of Intervention
HRH HRH
1. GnRH 2. GnRH
3. Steroid 4. Male Pill

5. Vaccin 6. Sperm Maturation
7. Tubectomy 8. Vasectomy
9. Tubal Transport 10. Capacitation

11. Vaccin
12. Coitus Interruptus,condom
14. Diaphraghm
13. Periodic Abstinence
15. Spermaticides
17. Emergency Contraception
16. IUD
18. Prostaglandin
19. Menstrual Regulation
20. Abortion T 1
21. Abortion T 2
22. Lactation
A ffandi B . Research in Contraception : Emergency Contraception,.K ongres II PERM I,Surabaya,3-6Feb 2005

21
21
M enstrual C ycle
Interaction of
hypothalamus,
pituitary gland
and the ovary.
Negative and
positive
feedback
mechanisms:
Physiology of the Menstrual Cycle
M orphological &endocrinological changes during the menstrual cycle:
GENES INVOLVED IN REGULATION OF MALE REPRODUCTION IN MOUSE
A ffandi B . Research in Contraception : Emergency Contraception,K ongres II PERM I,Surabaya,3-6 Feb 2005
Matzuk & Lamb. Nat Cell Biol 2002, 4:s41-9 24
24
FEMALE FERTILITY PROTEINS
25
25
Matzuk & Lamb. Nat Cell Biol 2002, 4:s41-9
Current Contraceptive Users
Indonesia, March 2005
METHODS USERS %
INJECTABLES 9,743,550 35.2

PILLs 7,796,474 28.1
IUDs 5,218,196 18.8
IMPLANTABLES 3,156,705 11.4
STERILIZATION 1,515,406 5.5
OTHERS 278,473 1.0
TOTAL 27,708,804 100.0
BKKBN, 2006
26
PIL KB
27
Tra ns derm a l S ys tem
T he C o ntra c eptive P a tc h
28
Intra-uterine system:
M irena ®
 M etode jangk a panjang
– 5 tahun yang reversibel
 T ingk at k eam puhan
– pregnancy rate 0.5 dalam 5 tahun
32 mm
 K adar L N G sistem ic yang

rendah
LNG
 M enyebabk an perubahan
Reservoir dalam per darahan haid
 B iaya ~ US $ 450 I US +
Levonorgestrel P em asangan
20 µg/day
29
T he C ontra c eptive V a g ina l R ing :
N uva R ing ®
Flexible, soft,
transparent ring with
outer diameter of 54
mm and cross section
of 4 mm
30
31
NORPLANT® Capsule and
JADELLE® Rod, Actual Size
32
IUD-Cu
33
33
Primary infertility means that the couple
has never conceived, despite cohabitation
and exposure to pregnancy for a period of 2
years.
Secondary infertility means that the couple

has previously conceived, but is
subsequently unable to conceive despite
cohabitation and exposure to pregnancy for
a period of 2 years. Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990
34
Attribution of the cause of infertility
D eveloping countries (% )
D eveloped L atin Eastern

countries A frica A sia A merica M editerran
(% ) ean
M ale cause only 22 8 13 22 19

Female cause only 31 37 34 25 25
Cause found in both 21 35 24 30 38
No cause found 14 5 13 10 3
Became pregnant 12 15 16 13 15
35
Specific causes of female infertility

countries A frica A sia A merica M editerra
(% ) nean
No demonstrable cause 40 16 31 35 26
Tubal factor 36 85 39 44 42
Ovarian factor 33 26 34 31 40
Endometriosis 6 1 10 3 1
36
Specific causes of male infertility

countries A frica A sia A merica M editerrane
(% ) an
No demonstrable cause 49 46 58 41 28
Sperm defect 21 13 19 25 33
A ccessory gland 7 11 3 12 3
V aricocele 11 20 10 19 12
37
Gap between mean age at marriage
and mean age at menarche
20 e
marriag
Age (years)
A g e a t
Age at m
enarche
10
1900 1920 1940 1960 1980
38
Percentage of adolescents reported to have
experienced premarital sexual intercourse by
a certain age, selected countries
A ge Ever having intercourse (% )
Country (years) M ales Females
A ustralia 20 58 47
W est Germany 16 35 30
Israel 14-19 42 11
Japan 16-21 15 7
Nigeria 14-19 68 43
Rep. of K orea 12-21 17 4
39
Percentage of women who are married
by ages 10-24, selected countries
A ge group (years)
Country 10-14 15-19 20-24
Bangladesh 8.2 64.7 91.0

Indonesia 0.8 24.6 66.2
17.7
M exico - 56.6
37.4
Pakistan 1.3 75.3
14.5
Peru - 49.0
3.2
Rep. of K orea - 43.6
6.2
Sri L anka - 37.8
40
Annual worldwide incidence of the
major sexually transmitted diseases
D isease Millions
Trichomoniasis 120
Genital chlamydial infections 50
Genital human papillomavirus infections 30
Gonorrhea 25
Genital herpes 20
Infectious syphilis 3.5
Chancroid 2.0
Total 250
In additional, over 1 million people a year are newly infected with HIV
WHO, 1993
41
Global Problems
P roblem s N
Unmet Need Contraception 120 million
Unintended Pregnancies 80 million
Induced A bortions 50 million
M aternal D eaths >0.5 million
Child D eaths 5 million
Infant D eaths 10 million
Sexually Transmitted Infection 340 million
Infertile Couples 90 million
Lancet, 2006
42
Estimated burden of sexually
transmitted infections in society
Chancroid
Syphilis
Gonorrhoea
Chlamydia
Infection increaseingly
asymptomatic
Trichomonas
Increasingly risky
Sex practices
Genital herpes
Human
papilloma virus
Lancet, 2006
43
Improving reproductive health
Socioeconomic conditions
Status of women
Sexual behavior
Reproductive behavior
Traditional practices
Health care services
Health professionals
44

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B iran A ffandi

D epartment of Obstetrics & Gynecology

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

Success outcome of pregnancy

Safety pregnancy and childbirth

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

China 1222 1526 +25

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

3. Steroid 4. Male Pill

9. Tubal Transport 10. Capacitation

19. Menstrual Regulation

A ffandi B . Research in Contraception : Emergency Contraception,.K ongres II PERM I,Surabaya,3-6Feb 2005

INJECTABLES 9,743,550 35.2

 K adar L N G sistem ic yang

Secondary infertility means that the couple

D eveloped L atin Eastern

M ale cause only 22 8 13 22 19

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

D eveloped L atin Eastern

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

D eveloped L atin Eastern

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

1900 1920 1940 1960 1980

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

Bangladesh 8.2 64.7 91.0

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