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Opinion: Integrated Reproductive Health Services: Where Do We Go From Here? |
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To fulfill the promise of the integrated approach to reproductive health, we must move beyond rhetoric to practical operational research and cost-effectiveness studies. A woman comes to the Chitwan State Clinic in the Nepalese city of Bharatpur seeking contraceptives. While discussing her family planning needs with a provider, she mentions that she has been experiencing pain in her lower abdomen. The provider carefully explains that this symptom could be a sign of a sexually transmitted disease (STD) and suggests that the woman see the clinic's physician. The doctor talks to the woman about her symptoms, does a pelvic examination and asks her some questions to assess her risk of sexually transmitted infection. Then he tells the woman that she probably has an STD and explains the importance of taking all the prescribed medicine, even if she feels better after a few days. He advises the woman on how to prevent further infection, and the assisting staff nurse gives her a wallet of condoms and a referral card for her husband. The nurse also provides tips on how to convince the husband to seek treatment. The nurse asks the woman to stop in the clinics' Health Education Room on her way out. There she meets with a woman health educator who demonstrates how to use a condom and gives her a simple brochure about STDs and HIV/AIDS. Before leaving the clinic, the woman sits for a few minutes to watch a short, entertaining videodrama about condom use and HIV/AIDS prevention. This clinic run by the Family Planning Association of Nepal (FPAN) exemplifies a global trend in women's health care: comprehensive reproductive health care that integrates STD prevention and treatment into long-established and better-funded family planning and maternal-child health (MCH) services. The logic behind integrated services is straightforward. Women who defer treatment for a suspected STD rather than risk the social stigma of using an STD clinic would probably feel more comfortable seeking care at a family planning or MCH clinic that they already patronize. And because STDs can affect not only a woman's health but also contraceptive efficacy, fertility and neonatal outcome, the incorporation of STD diagnosis and treatment into family planning and MCH services could mean better contraceptive and obstetrical results. Such "one-stop" shopping also offers the potential for cost savings and more efficient use of often-scarce resources. Support for integrated reproductive health services has grown worldwide. The concept was strongly endorsed at the 1994 International Conference on Population and Development in Cairo. Since then, numerous international health and development organizations have called for integration of STD, HIV/AIDS, family planning and MCH programs. Yet despite such support, the promise of integrated reproductive health services is far from fulfilled. Clinics like the one described above are still rare. With a few exceptions, attempts to integrate STD prevention and treatment into family planning and MCH services have been half-hearted or technically incorrect. Why haven't we seen more progress in integration -- and what will it take to move forward? Perhaps a reality check is the way to start. First we must recognize that the integration ideal that inspires conference declarations and policy papers may be too ambitious for resource-poor health care systems. Equally important are the long-overdue evaluation studies and operations research that can confirm whether integration is feasible and cost-effective in different settings. Once this solid foundation of knowledge has been laid, a final problem -- the lack of widely recognized program and technical guidelines -- can be tackled. A Critical Need Compared to family planning and MCH, STD programs have historically been underfunded and poorly resourced. With the advent of the HIV/AIDS epidemic, that second-class status persisted as better-funded HIV prevention programs appeared in response to a fast-moving, lethal epidemic. Yet as evidence mounts that certain sexually transmitted infections increase susceptibility to HIV as much as ninefold and that untreated STDs have severe consequences in women and children, STD prevention and treatment are receiving new attention. The value of effective STD services is reaffirmed with each new research effort. Recent research in Malawi showed that treating men for urethritis also reduces the concentrations of HIV found in their semen, making them less likely to transmit the virus to their partners.1 And most convincingly, a community-based trial in the Mwanza district of Tanzania found that using the syndromic approach to treat STDs reduced HIV incidence in the study population by a stunning 42 percent.2 As awareness of the importance of STD prevention to HIV/AIDS control grows, so does a renewed appreciation of the threat that STDs themselves pose to women. In women 15 to 44 years of age, STDs are second only to maternal morbidity and mortality as a cause of healthy years of life lost. And in many developing countries untreated STDs are the leading cause of infertility in women -- a devastating emotional and social blow in communities where motherhood defines a woman's identity. STDs in women often go untreated because the women have no symptoms. Even when they do have symptoms, many women do not seek treatment because they do not recognize the symptoms or they fear the stigma of attending an STD clinic. Failure to treat an STD has debilitating -- sometimes even fatal -- consequences. For example, a frequent complication of untreated gonorrhea or chlamydial infection in women -- pelvic inflammatory disease (PID) -- can lead to ectopic pregnancy, with subsequent maternal death or chronic pelvic pain and pelvic infections. PID also accounts for much of the infertility that occurs in the developing world: an estimated 66 percent in African women and 34 percent in Asian women. The impact of STDs on pregnancy outcomes and children's health is equally severe. Untreated STDs in pregnant women can result in fetal loss, prematurity and low birth weight. For example, about 40 percent of pregnancies in mothers infected with syphilis end in spontaneous abortion, stillbirth or perinatal death. Maternal infections can also be passed on to unborn children, causing congenital syphilis, ophthalmia neonatorum (eye infections that can lead to blindness without treatment) and chlamydial pneumonia in newborns. Barriers to Integration Given the terrible costs of untreated STDs, it's little wonder that many public health specialists hope that integrated reproductive health services will bring long overdue attention to STD prevention and treatment. Unfortunately, support for the concept of integration has greatly outpaced efforts to address the technical, financial, programmatic and psychological constraints that impede its implementation. Many clinics do not have the resources to provide full-scale STD services to their clients. For example, many do not have the staff to handle the increased responsibilities or the funding to hire more personnel. Clinic staff often are not trained to treat STDs, and programs may not be able to afford the ongoing training and supervision required to ensure quality services. Space for examination rooms and private counseling sessions is not always available, and STD drugs may be too expensive or difficult to procure. Community outreach is important to a program's success, but requires funds for developing outreach materials as well as staff time. Other barriers to integrating services are cultural and psychological, sometimes involving deeply ingrained negative attitudes about STDs and those who suffer from them. Family planning and MCH program managers are not immune to the stigmatizing attitudes of the society around them and sometimes fear "contamination" of their clinics' reputations and loss of clientele if they offer STD services. Many family planning providers are reluctant to promote the use of condoms, which they consider an unreliable, ineffective and unpopular method of contraception. And some professional staff trained in standard diagnosis and treatment practices may also feel uncomfortable with the syndromic management approach to STD management that is recommended for settings where laboratory testing is slow, too expensive or unavailable. Even when programs do seek to integrate their services, guidance about what integration is and how it should "look" are largely absent in the public health literature. Without an operational definition of integration, many programs struggle to respond to entreaties to integrate, unsure of how to proceed, and misunderstand or misapply important concepts and methodologies. One example is the use of risk assessment for STD case finding. Algorithms used in the syndromic management of vaginal discharge now incorporate a risk assessment tool to distinguish symptomatic women who are likely to have a cervical infection from those with vaginal infections. Some newly integrated programs have adopted this risk assessment as a way to identify STDs in women who have no symptoms, even though studies do not validate such use of this tool. Ultimately, this misappropriation of the methodology could unfairly discredit the syndromic approach. Other consequences of the lack of systematic procedures for integration involve sins of omission rather than commission -- but with equally serious consequences. Many family planning and MCH clinics that claim to have integrated programs concentrate on HIV prevention education but do not include STD information or screening histories. This is often true of community-based HIV prevention programs as well. As a result, it is not unusual for people to have a better understanding of HIV than STDs, even though their risk of acquiring an STD outweighs their risk of HIV infection. Many "integrated" programs -- and most antenatal clinics in the developing world -- also neglect to screen for syphilis, even though the serological test for syphilis is simple to perform and both the test and the treatment are inexpensive. Experience in Jamaica has shown that clinic staff with little or no laboratory experience can be trained to perform syphilis blood tests with high levels of accuracy.3 Screening for syphilis is particularly important in antenatal clinics because untreated maternal syphilis can lead to transmission of the infection from mother to child, which can cause fetal loss, perinatal and infant death, and long-term childhood illness. All of these adverse pregnancy outcomes can be prevented through routine serological screening and early treatment of both partners. Moving Forward It's time to recognize that integration of reproductive health services is not an all-or-nothing endeavor. Given the wide-ranging economic, technical, cultural and social constraints, small steps toward integration are both legitimate and valuable. As long as the methodology is sound, MCH and family planning programs can incorporate aspects of STD prevention and treatment into the work they already do, building familiarity with and confidence in the integrated approach. For example, many family planning clinics could assess women for STD symptoms and educate clients about STD transmission, prevention, complications and treatment. Setting up referral networks for women with STD symptoms when a clinic is not prepared to offer treatment is more of a challenge, but certainly not impossible. At a minimum, there should be routine syphilis screening of women at all antenatal clinics and prevention counseling and referral at family planning and MCH sites. Offering these basic services will require behavior change on the part of many -- but not all -- providers. Indeed, providers in a Kenyan family planning clinic serving a high-risk population asked for training in STD management because patients had requested treatment for STD symptoms. But many providers need training not only to increase their technical capacity to deal with STDs but also to change their attitudes toward patients with these diseases. It's also time to invest in operations research to answer a number of important questions. For example, policymakers and program managers need to know how much it costs to add STD prevention and treatment to family planning and MCH services, how such integration affects clients' use of contraceptives (including dual method use), and whether it improves the quality of all reproductive health services. Research is needed to identify the best approaches to STD prevention and treatment education in clinics and the optimal mix and level of STD services in different settings. And in settings where full integration is not possible, program managers need to determine the most viable options for referrals. Cost-effectiveness studies are essential to determine whether integration of reproductive health services is advisable in specific settings. In areas where STD prevalence is low, for example, the benefits of integrating services might not offset the costs. On the other hand, when STDs affect a substantial proportion of the population served by a family planning or MCH clinic, the cost of failing to integrate might be even higher than the time and expense required to train staff and provide additional services. These are hardly abstract research questions, and finding answers to them will enable program managers to make sound decisions about when, if and how to integrate services. They will also provide operational definitions and procedures to make integration more effective and less difficult to accomplish. Integration of services is one route to improving women's reproductive health, not an end in itself. It's not easy to develop programs that are scientifically valid, responsive to patients' needs, and affordable and feasible in an era of ever-scarcer resources. Taking the slow but steady road toward integration may not eliminate all the obstacles, but the destination -- an effective and comprehensive approach to reproductive health services -- will enhance the health of women, children and communities. References
Mary Lyn Field, MSN, FNP, is the senior program officer in AIDSCAP's STD Unit. Gina Dallabetta, M.D., is the project's director for technical support. |
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