Reproductive health

approaches
Lecture by :
Samuel N(BSc, MPH/RH)
Jimma University
February,2023
2 Session outline

 Reproductive health approaches

 Life cycle approach
 Life course approach
 Reproductive health rights & right Based approach
3 RH

“ a state of complete physical, mental & social well-being, & not merely the absence of
disease or infirmity, in all matters relating to the reproductive system & its functions &
processes.”at all stages of life and implies that people are able to have a satisfying and safe
sex life, and that they have the capability to reproduce and the freedom to decide if, when,
and how often to do so.” (ICPD 1994)
4 Why a reproductive health approach?

 A broad reproductive health approach is preferable to a maternal health approach for

several important reasons:
1. First, it is very difficult to define where maternal health begins. In dealing with maternal
health problems, one should recognize that health problems in early childhood and
adolescence contribute to conditions that may interfere with safe sexuality, pregnancy and
delivery in Iater life. Because the foundations of health are laid during childhood and
adolescence, a reproductive health approach encompasses nutrition, development, education,
and the socioeconomic environment girls and adolescent women experience.
5 Why a reproductive health approach?

2.A reproductive health approach also recognizes that maternal mortality, currently the main
indicator of women’s health, is just the tip of the iceberg of the problems caused by sexuality
and pregnancy. The extent and nature of morbidity have yet to be systematically measured, but
it has been estimated that, in developing countries, for every woman who dies in pregnancy
another l0-15 suffer serious impairment
Many conditions are exacerbated by pregnancy or are a greater problem to pregnant women.
Morbidity resulting from or exacerbated by pregnancy is thus an important element in
reproductive health that needs much more attention.
6 Why a reproductive health approach?

3. A reproductive health framework facilitates more comprehensive assessment of the relative

risks of childbearing and fertility control. It is necessary to look at all women of reproductive
age, not just pregnant women, in assessing the absolute and relative risks of pregnancy,
abortion, and various methods of contraception.
7 Why a reproductive health approach?

 4.Finally service provision could benefit from a broader definition of reproductive

health .A narrow emphasis on women as mothers, reflected in the provision of services
through maternal and child health (MCH) and family planning channels, usually means
that many women are not served, and that many reproductive health problems go
unrecorded and untreated. MCH and family planning services do little to meet the
reproductive health needs of male and female adolescents, men, the unmarried, the
infertile, those with sexually transmitted diseases, and, in many countries, those with
unwanted pregnancies.
 The International Conference on Population and Development (ICPD, Cairo, 1994) broke
new ground in endorsing men’s involvement in sexual and reproductive health, a realm
that until then had overlooked their active role.
8 Reproductive health approaches

 The shift to population and development adopted by the ICPD PoA in Cairo in 1994, and
the principles of a people-centred, life cycle approach marked a step forward in defining a
new framework based on sustainable development, with the individual as the focus, rooted
in human rights, with due attention paid to environmental sustainability
 The great transition in Cairo - from "counting the people" to "the people count"
 Women are ends and not means; The basic premise of the reproductive health approach is
that reproductive health needs should be met within the premise that women are ends and
not means.
 Family planning' however' can be and has been used by govemments and others to control
rather than to empower, women' The family planning movement in the past has been
largely demographically driven. As far as policymakers were concerned, women are often
objects and not subjects'
9 Reproductive health approaches

 In 2014, the United Nations Secretary-General released a report that documented the
achievements, gaps, challenges, and emerging issues related to implementation of the PoA
 While there has been substantial progress in delivering on the Cairo promise, it has been
fragmented, as new challenges and opportunities emerge. The quality of care of
reproductive health services has improved, but contraceptives prevalence still remains low,
especially in poor communities, and among adolescents and the unmarried. The adolescent
birth rate is still very high in poor regions, with higher rates in the poorest and least
educated areas
10 SDG

 What are the Sustainable Development Goals?

 These goals, also known as the SDGs, aim to end poverty, protect the planet and ensure
prosperity for everyone by 2030.
 This Agenda is a plan of action for people, planet and prosperity
 Nearly all the countries in the world have promised to improve the planet and the
lives of its citizens by 2030.
 They’ve committed themselves to 17 life-changing goals and 169 targets, outlined by the
UN in 2015. These targets, known as the Sustainable Development Goals (SDGs), include
ending extreme poverty, giving people better healthcare, and achieving equality for
women.
 The aim is for all countries to work together to ensure no one is left behind
11 SDG

 The Goals and targets will stimulate action over 15 years in areas of critical importance
for humanity and the planet
 People- We are determined to end poverty and hunger, in all their forms and dimensions,
and to ensure that all human beings can fulfil their potential in dignity and equality and in
a healthy environment
 Planet- We are determined to protect the planet from degradation, including through
sustainable consumption and production, sustainably managing its natural resources and
taking urgent action on climate change, so that it can support the needs of the present and
future generations
12 SDG

 Prosperity- We are determined to ensure that all human beings can enjoy prosperous and
fulfilling lives and that economic, social and technological progress occurs in harmony
with nature.
 Peace- We are determined to foster peaceful, just and inclusive societies which are free
from fear and violence. There can be no sustainable development without peace and no
peace without sustainable development.
 Partnership- We are determined to mobilize the means required to implement this
Agenda through a revitalized Global Partnership for Sustainable Development, based
on a spirit of strengthened global solidarity, focused in particular on the needs of the
poorest and most vulnerable and with the participation of all countries, all stakeholders and
all people
13 SDG Goal and Targets pertinent to RH

 Goal 3.Ensure healthy lives and promote well being for all at all ages
 3.1- By2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live
births
 3.2-By 2030, end preventable deaths of newborns and children under 5 years of age, with
all countries aiming to reduce neonatal mortality to at least as low as 12 per1,000 live
births and under 5 mortality to at least as low as 25 per 1,000 live births.
 3.7- By 2030, ensure universal access to sexual and reproductive health care services,
including for family planning, information and education, and the integration of
reproductive health into national strategies and programmes.
SDG Goal and Targets pertinent to RH
 Goal5.Achieve gender equality and empower all women and girls
 5.1-end discrimination against women and girls everywhere
 5.2-end all violence against and exploitation of women and girls in the public and private
spheres, including trafficking and sexual and other types of exploitation
 5.3- Eliminate all harmful practices, such as child, early and forced marriage and female
genital mutilation
 5.4-value unpaid care and promote shared domestic responsibilities
15 SDG Goal and Targets pertinent to RH

 5.5-ensure full participation in leadership and decision-making

 5.6-universal access to reproductive health and rights
 5.7-equal rights to economic resources, property ownership and financial services
 5.8-promote empowerment of women through technology(ICT)
 5.9-adopt and strengthen policies and enforceable legislation for gender equality
16 Reproductive health approaches

 To mark the 25th anniversary of ICPD in 2019, the Nairobi Summit came up with a series
of interrelated Nairobi Commitments, the aim being to achieve goals ranging from zero
unmet needs for contraceptives, and zero preventable maternal mortality to zero levels of
gender-based violence, while addressing the sexual and reproductive health needs of
adolescents
 The Commitments aligned to a life cycle approach to address the importance of life cycle
experiences on the individual’s life from conception to infancy, adolescents reproductive
age, and old age.
17 Reproductive health approaches

 To reduce the number of maternal deaths, women need access to good-quality sexual and
reproductive health care and effective interventions that keep people on the radar of
implementing the development process. The SDGs brought a more focus on people, and
therefore a more people centered approach became relevant. The discussion reported
agreement that key stages in people’s lives have relevance for their health, particularly
reproductive health, and life stages are linked to each other. Thus, a life cycle modelling
also became relevant to the key interventions by development practitioners and UN
agencies including UNFPA and WHO.
18 The 3 UNFPA transformative results

 UNFPA Transformative Results :UNFPA aims to achieve three world-

changing results by 2030, the deadline for achieving the Sustainable Development Goals
 1. Zero preventable maternal deaths
 In order for a people-centered life cycle to achieve a zero maternal death level, the
appropriate interventions and programmes should involve participation by women and
adolescent girls at the planning and design stage. This at least would ensure that service
provision is in line with their educational and learning preferences, and that services
catering to the differing needs of the life stages involve not just married women but also
adolescents and unmarried women.
19 Zero preventable maternal deaths
20 The 3 UNFPA transformative results

2. Zero GBV and harmful practices

Here the focus in on eliminating all forms of discrimination against women and girls in order
to release and realize the individual’s full socio-economic potential. Worldwide, women and
girls are at risk of different forms of violence at all ages, ranging from prenatal sex selection
all the way through to the abuse of widows and elderly women
21 Zero GBV and harmful practices
22 The 3 UNFPA transformative results

3. Zero unmet need for family planning

Despite progress since Cairo 1994, multiple barriers still exist, and millions of people, women
especially, still have not fully realized their sexual and reproductive rights. It is a given that
190 million women want to avoid pregnancy and yet they do not use any contraceptives
method.
About 25 million women undergo unsafe abortions, while one-in-three women experience
intimate partner violence or non-partner sexual violence at some point in their lives exposing
them to unwanted pregnancies and forced and unsafe abortions. Access to and the availability
of family planning and contraceptives is the mainstay for women to prevent unwanted
pregnancies and avoid unsafe abortions
23 Zero unmet need for family planning
24 Zero unmet need for family planning

 People-centred lifecycle for zero unmet need to family planning involve three important
tasks
1. Creating demand through awareness-raising and spreading knowledge and skill starting at
an early age and including all women and men of reproductive age regardless of their marital
or union status. It is important for young adolescents to acquire knowledge about the
importance of contraceptives and family planning.
25 Zero unmet need for family planning

2. Responding to demand through comprehensive service packages that include a variety of

affordable methods for women and men of all ages from different settings, regardless of their
economic welfare, is essential. Accessibility is the key here given the personal, community,
economic, and cultural challenges that need to be overcome.
26 Zero unmet need for family planning

3. Adopting a people-centered approach by involving the intended beneficiaries in the design

and ownership of the requisite response interventions and building on existing systems to
ensure the sustainability of programmes is advisable.
27 Components of Rh services
28 Life cycle approach to RH

 A life cycle approach begins with the concept that the well-being and capabilities of an
individual - particularly his/her health - depends on a cumulative and interlinked process.
When it comes to health, that process requires access to health care, living in a safe
environment, plus the accumulation of education, training and skills. Certain phases of life
are crucial to this process. Starting from the early years, survival is key
29 Life cycle approach to RH

 The idea behind the life cycle approach is about how each individual life span -our
capabilities, our health, our productivity in economic terms - depends on the choices that
are made at an earlier stage in the life cycle and how each step of our lives connects and
leads to the next
30 Life cycle approach to RH
31 Life cycle approach

 Studies show that the factors that may have influenced a current health situation are often
associated with other life cycle factors, from conception, infancy and childhood,
adolescent, reproductive years, and post-reproductive years, onwards into old age.
 Preparation for a healthy pregnancy, through preconception care and the prevention of
unplanned pregnancies has attracted academic and policy attention in recent years but still
falls far short of being provided routinely. The aim of preconception care is to intervene
before pregnancy to improve short­term and long­term health and wellbeing outcomes for
people of reproductive age, and for any future children they might have
32 Life cycle approach

 Yet 90% of women of reproductive age have at least one modifiable risk factor that can
affect pregnancy, making preconception health an important factor in maternal deaths and
inequalities in maternal out comes,as identified by the UK Government’s Maternity
Disparities Taskforce.
 The Lancet Series on preconception health was published in 2018, at the same time that
Public Health England produced a suite of resources making the case for preconception
care. These reports and resources emphasized the need to address inequalities and upgrade
prevention efforts through embedding universal (ie, population ­level) and targeted (ie,
individual ­level) preconception care in a life course framework.
33 Life cycle approach

 WHO recommends action for preconception care by leveraging existing public health
programmes, including community ­based health care, and by exploring innovative
channels
 Innovative channels covers digital interventions, school­based education, and social media
campaigns that do not rely on contact with health services. We build on these resources by
summarising the evidence for components of effective and acceptable preconception and
interconception care interventions, and by considering opportunities for integration of
these interventions in community­based care.
 folic acid uptake, reductions in alcohol consumption &smoking, nutrition, and
engagement with health­care providers, improved glycaemic control for women with
diabetes
34 Life cycle approach

Interconception interventions
Effective interconception interventions included risk assessments that lead to tailored care, and
multiple intervention and education components, such as counselling, multivitamin
supplementation, peer support groups, contraception support, and mental health support.
Outcomes including postpartum weight retention and glycaemic control after gestational
diabetes are potential proxy measures for health in any future pregnancies, and post­partum
interventions that address these risk factors show promise
35 Life cycle approach

 A woman’s health directly influences the health and development of the child. Access to
timely and responsive health services, including skilled birth attendant are essential.
Mothers can be vectors for transmitting communicable diseases to their babies including
HIV/AIDs. For the child, infection is a major killer during pregnancy, and can otherwise be
accountable for low birthweight
36 Life cycle approach

 The starting point in the life-course of health and development is that every baby should be
a wanted baby. Unwanted pregnancies may lead to unsafe abortions, child neglect,
malnutrition, disease, and social problems
 This implies effective contraceptive advice and service availability as young people
approach puberty and during their reproductive years.
 WHO’s “European Health for All” illustrates basic needs for each life stage as follows:
37
Life cycle approach

 1. Infancy – Childhood 0-9 years old: at this age, children are exposed to differential
feeding and nutrition discrimination as well as health care that favors a boy child,
especially in poorer communities. These factors amount to an unfair initiation to life that
can be critical for a girl child’s health during adolescence, and adulthood. Other issues
include missing girl child due to sex selection cause dramatic decline in sex ratio, and
selected abortion.
 The first 28 days of the baby’s life are critical, this being the period when the baby is at
highest risk of death. Neonatal death is largely the result of socio-economic circumstances,
including access to appropriate services at the time of delivery, and parental education
38 Life cycle approach

Over 40% of the global burden of disease is attributed to environmental risks that affect
children under five years of age. 1 in 13 children in low- and middle-income countries die
before the age of five, deaths due to preventable conditions such as pneumonia, malaria,
malnutrition, all associated with environmental factors like lack of clean water, and sanitation.
Over the last three decades, scientific findings from a range of disciplines have confirmed that
early childhood development lays the foundation for health, learning, productivity and well-
being throughout a person’s life.
Scientific evidence shows that children who lack nurturing care as part of early childhood
development may be less healthy, grow poorly, learn less and complete fewer grades at school.
They may have difficulties relating confidently to others and earn less as adults.
39 Life cycle approach

 2. Adolescents 10-19: Early childbearing by adolescent girls, abortion, gender-based

violence, STDs, RTIs HIV/AIDS, under-nutrition, are among the health threats girls may
face during this period.
 Although vaccines protect children, other diseases like hepatitis A can be prevented by
good hygiene. Among the environmental factors that may play a role are tobacco smoke,
asbestos, ultraviolet light radiation, and pesticides. Parental lifestyle and social interactions
beyond the family, such as school environment, peer pressure, and mass media, are
increasingly influential in determining a child’s values, attitude and behavior patterns
 Many adolescents die prematurely because of accidents and risky behavior. Adolescent
girls particularly from poorer environments are especially vulnerable to gender-based
violence, unwanted pregnancies, and early marriage
 It is time for HPV vaccination for female adolescents
40 Life cycle approach

 Accidents, violence, and suicide are among the three most common causes of death in
adolescence . Adolescence is also a period of experimentation and rebellion against
authority. This is the age when the use of tobacco, alcohol and drugs can become
established habits. Their use is a major contributing factor to accidents, suicides, violence,
unwanted pregnancies and sexually transmitted diseases among young people in many
countries
41 Life cycle approach

 3. Reproductive Health years 20-44 years old: Unplanned pregnancies, coercive marriages,
unmet needs for family planning, harmful practices, RTIs STDs, HIV/AIDS.
42 Life cycle approach

 4. Post-reproductive years 45+: Cancer including breast cancer, cervical cancer,

gynecological problems, osteoporosis, cardiovascular problems, diabetes
 Although there is some evidence that sexual activity declines with age, there is also a clear
view that many adults remain sexually active well into old age , adjusting and adapting to
disability and disease to continue to enjoy fulfilling sex lives
43 Life cycle approach

  People aged 60 years or over living in the world in 2017 estimated to be 962 million, with
a further doubling projected by the year 2050, at 2.1 billion.
 Two-thirds of the older population aged 60 years or over live in low- and middle-income
countries, where their rate of growth has been faster compared to high-income countries.
 Sexual and reproductive health and rights (SRHR) issues in older adults remain a “taboo”
among individuals and in many societies at large, a “topic of minimal interest” for health
professionals and researchers; and a “blind spot” in the broader policy dialogue . This
minimal focus remains despite the global call for the need to implement a lifecourse
approach, from pre-pregnancy to post-reproductive years, in tackling SRHR issues .
44 Life cycle approach

 There are undoubtedly several SRHR issues relevant to the older population. For older
women, a sharp decline in oestrogen and progesterone levels leads to declining ovarian
function and then to several physical and psychological changes experienced as part of the
peri-menopausal syndrome, including reduced libido, lack of energy, osteoporosis,
irritability and mood swings.
 Older men, on the other hand, have reductions in their testosterone levels and sperm
production gradually becomes lower, there is also a decrease in lean body mass, decrease
in body hair, skin alterations, erectile dysfunction, and increase in visceral fat and obesity
45 Life cycle approach

 For both men and women, there is also the impact of non-communicable diseases and
medications that older people typically take, and their impact on libido, erectile
dysfunction and energy levels. Non-communicable diseases at older age are exacerbated in
women as a result of the cumulative impact of pregnancy and childbearing during the
reproductive age.
 For older people, there is a general perception that they do not have any sexual desires and
even if they do, in many cultures, they are not expected to speak about such matters .
However, available evidence suggests that more than 80% of men and 65% of women
remain sexually active in old age
46 Life cycle approach

 Of course, what this sustained sexual activity into old age means is that there remains a
risk for sexually transmitted infections (STIs) and Human immuno-Deficiency Virus (HIV)
infection amongst the older population [13]. For older women, in particular, the increased
vaginal dryness, atrophy of the vaginal wall and loss of lubrication which they experience
as part of menopause, interfere with sexual comfort and pleasure. These symptoms also
limit the effectiveness of innate vaginal protective mechanisms against STIs and HIV
infection
47 Life cycle approach

 Older persons can be especially vulnerable to abuse and domestic violence. Hostility
against elderly people who have been widowed and begin sexual relations again is not
uncommon. Such reactions are part of a social mythology that rejects any manifestation of
sexuality between older persons.
 Since women live longer than men, they account for the bulk of the ageing and elderly
population, with elderly poor women being especially vulnerable in many countries
48 Life course approach to RH

 A life-course approach considers an individual’s entire progress throughout life to explain

why certain outcomes result. The outcomes depend on the interaction of multiple
protective and risk factors throughout people’s lives. A life-course approach examines how
biological (including genetics), social and behaviouraI factors throughout life and across
generations act independently, cumulatively and interactively to influence health outcomes
49 Life course approach to RH

 Sir Michael Marmot set out the lifecourse approach as a way to conceptualize the way an
individual accumulates positive and negative health impacts through their life. Although
some of these may be mitigated or fade with time, many have impacts that continue
throughout life and may have a cumulative effect as they interact with new impacts
50 Life course approach to RH

 All these factors can be categorised as protective factors or risk factors.

51 Life course approach to RH

 A life course approach to reproductive health asks a range of questions that are relevant to
development of health policy. For example, does birth weight influence the age of
menarche and menopause?
 What is the influence of childhood growth on age at menopause and this modified by adult
body size? Could the link between reproductive health and other chronic diseases be due to
a common set of factors that affects them both and, if so, when and what is the way to
intervene?
 What is the impact of grandmother’s fertility rate on that of the granddaughter’s ?
52 Rationale for adopting the life course approach

 By taking this long term approach, we can start to consider the fundamental causes behind
health and well-being conditions and ensure actions nationally and locally will have the
most impact on outcomes
 Therefore the interventions we invest in now across the life-course will be beneficial later
as well if they are effective at reducing the burden of disease as the total population of
older people increases
53 The continuum of care and the life course
approach
 In the critical area of SRH, the emphasis has been predominantly on maternal and newborn
health, specifically the physical health of women during pregnancy and delivery and their
health and that of their newborn in the first few weeks thereafter. A core principle that has
been advocated by the WHO to improve maternal, newborn and child health (MNCH) is
the adoption of a “continuum of care” approach by programmes and policy makers
54 The continuum of care and the life course
approach
 This approach has 2 features. To begin with, such an approach means essential MNCH
care must be provided “vertically” from the individual household, to the community to the
health facilities. Secondly, it means that care also needs to be provided in a life-course
approach throughout the various stages of life (i.e. pre-pregnancy, pregnancy, the neonatal
period, infancy and childhood, adolescence, and into the post-reproductive stage) in a
continuous and seamless manner
55 The continuum of care at the level of the health
system
56 Reproductive health rights & right Based
approach
 Sexual and Reproductive Health and Rights (SRHR) are a relatively new concept.
Reproductive rights were first officially recognised at the International Conference on
Population and Development (ICPD) in Cairo in 1994. Agreed by 179 countries, it was the
first and most comprehensive international document to embody concepts of reproductive
health and rights and sexual health.
 For the first time, there was a clear focus on the needs of individuals and on the
empowerment of women, and the emergence of an evolving discourse about the
connection between human rights and health, linking new conceptions of health to the
struggle for social justice and respect for human dignity
 Prior to this, reproductive health programming had emerged from concern about
population control and focused on family planning, fertility control and safe motherhood
only.
57 Reproductive health rights & right Based
approach
 The Beijing Platform of Action, 1995, was the first declaration to embody the concept of
sexual rights
 At the Fourth World Conference on Women in Beijing, 189 governments also recognized
that social and cultural discriminations, gender inequalities but also the lack of information
and services contribute to sexual and reproductive ill health
 The Beijing conference also firmly stated that women’s rights are human rights and that
women’s sexual rights are part of their human rights
58 Reproductive health rights & right Based
approach
 Last but not least, in October 2007, the target of universal access to reproductive health
was eventually included in the Millennium Development Goals (n°5) while it had been
excluded in 2000 when the MDGs were first discussed. Based on this global political
reaffirmation of the ICPD agenda, reproductive rights are now considered a human rights
for all people, including universal access to reproductive health throughout their life cycle.
59 Reproductive health rights & right Based
approach
 The new attention to human rights in the ICPD marked a departure from the previous
approach that treated women instrumentally, as tools through which to implement
population programmes and policies. The reproductive health and rights approach adopted
at ICPD is premised on a view that values women intrinsically and is genuinely concerned
about their health and well-being.
60 Reproductive health rights & right Based
approach
 Women’s reproductive capacity was transformed from an object of population control to a
matter of women’s empowerment to exercise personal autonomy in relation to their sexual
and reproductive health within their social, economic and political contexts
61 Rights Related to Sexual and Reproductive Health (SRH)

 Sexual and Reproductive Health and Rights (SRHR) includes following rights:
 the rights to equality and non-discrimination
 the right to be free from torture or to cruel, inhumane or degrading treatment or
punishment
 the right to privacy
 the rights to the highest attainable standard of health (including sexual health) and social
security
 the right to marry and to found a family and enter into marriage with the free and full
consent of the intending spouses, and to equality in and at the dissolution of marriage
62 SRHR…continued

 the right to decide the number and spacing of one’s children

 the rights to information, as well as education
 the rights to freedom of opinion and expression, and
 the right to an effective remedy for violations of fundamental rights
 Right to Benefit from Scientific Progress
63 references

 Banke-Thomas, A., Olorunsaiye, C.Z. & Yaya, S. “Leaving no one behind” also includes taking the
elderly along concerning their sexual and reproductive health and rights: a new focus for Reproductive
Health. Reprod Health 17, 101 (2020). https://doi.org/10.1186/s12978-020-00944-5
 Towards a Life Cycle People-Centered Approach to the Implementation of ICPD Programme of Action
,Sexual and Reproductive Health Case Study By UNFPA,and ICPD25, August 2021.
 THE LIFE-COURSE APPROACH IN SEXUAL AND REPRODUCTIVE HEALTH (SRH), WHO
Regional Office for Europe ,2015
 Banke-Thomas et al. “Leaving no one behind” also includes taking the elderly along concerning their
sexual and reproductive health and rights: a new focus for Reproductive Health (2020) 17:101
64 End

Thank you!