Reproductive health is life-long, beginning even before women and men attain sexual maturity and continuing beyond a woman's child-bearing years.
Family planning has traditionally focused on only one aspect of reproductive health care that is needed during a particular time of life -- providing safe, effective and affordable contraception. In addition to family planning, reproductive health care includes pregnancy and postpartum care, prevention and treatment of sexually transmitted diseases, pregnancy termination, cancer screening and infertility counseling, among other services. Related health concerns are numerous, including counseling about domestic violence or gender inequality.
Different stages in a person's life require different reproductive health services. Adolescents and unmarried women may not have access to effective contraceptive methods. Pregnant women need dependable emergency care that is quickly available. Women with reproductive tract infections and women who have terminated unwanted pregnancies may need special counseling.
Poor reproductive health accounts for a substantial portion of all deaths among women ages 15 to 49 worldwide.1 These deaths arise from complications during pregnancy or childbirth, from reproductive tract infections, and unsafe abortion. Domestic violence and sexual abuse contribute to these deaths, as well as to many injuries and illnesses.
"We continue to get more data showing women's reproductive health problems are far more prevalent than we previously thought," says Dr. Karen Hardee, a senior research associate at FHI. Some of these conditions can be improved by expanding family planning services into other areas of reproductive health care, she says, although careful planning and evaluation are necessary to determine which additional services would be feasible and worthwhile.
Limited resources
Expanding reproductive health services can be effective but also raises questions about how limited resources should be spent. Some experts maintain that many reproductive illnesses and deaths could be prevented or treated using technology currently available in most countries.2 In some countries, maternal health investments of US $1.50 a year per person of the total population can reduce maternal mortality by as much as 65 percent, according to Anne Tinker at the World Bank.3
A substantial number of family planning programs have already implemented services that go beyond contraceptive services. In 1993, the U.S. Agency for International Development surveyed 50 countries on reproductive health activities either ongoing or planned to begin by 1995. The survey divided reproductive health into four categories: family planning or safe regulation of fertility; maternal health and nutrition; protection from STDs; and reproductive rights. More than half of the agencies surveyed had already integrated some form of STD services with family planning, and one-fourth were providing services from all four categories.4
Combining services may improve efficiency by reducing duplication and minimizing the number of workers and facilities needed.5 In an evaluation by the Population Council, programs in Tegucigalpa, Honduras and Lima, Peru that combined postpartum services with family planning achieved a higher contraceptive prevalence and cost savings. In an experimental study in Lima, women offered contraception before hospital discharge were substantially more likely to be using contraception six months postpartum, compared to women who did not receive any family planning after childbirth. Because in-patient IUD insertion in Lima cost $9.38 per woman compared to $24.16 for out-patient insertion, implementing postpartum family planning at Peruvian Social Security Institute (IPSS) hospitals is expected to save about 5 percent of IPSS's annual family planning costs.6
However, integrating new health services into a family planning program may enhance one component of health care at the expense of another. Primary health care clinics in many countries already have many tasks to meet, says FHI's Dr. Nancy Williamson, who has written extensively on the integration of family planning and STD services.
"A lot of people have good will and want to cover a larger reproductive health need, but from a family planning perspective the question is, 'How can we find compatible activities without diluting family planning?'" asks Dr. Williamson, who directed the evaluation of a large maternal and child health and family planning integration project in the Philippines. "More thought needs to be given on how to integrate the activities for a worker or a client."
There are many reproductive health services that could be added to family planning services. Two of the most widely studied service categories include maternal health care and STD prevention or treatment.
STD prevention
Family planning programs may be an appropriate place to provide STD prevention and treatment because many of the functions overlap. Counseling on sexual activity (including abstinence) and providing barrier contraceptives, which help protect against STDs, are examples of related services, says Dr. Ward Cates, FHI's corporate director of medical affairs.
Having an STD increases a person's risk for HIV infection and transmission. STDs also contribute to reproductive tract problems in women, can harm unborn fetuses, and increase a woman's chances of developing cervical cancer.7 Most STDs, including syphilis, genital herpes, chancroid, genital warts, bacterial vaginosis, trichomoniasis, chlamydia and gonorrhea, increase a woman's risk for illness and death during pregnancy and childbirth. Swelling and infection in the upper reproductive tract can cause ectopic pregnancy, resulting in hemorrhage.
Family planning providers can prevent some of these infections through screening, condom distribution, couples counseling, maintaining hygienic facilities, and being sure that contraceptive services or procedures do not spread or aggravate infections.
Combining basic STD screening and some of the more inexpensive treatments with family planning may be easy to do and worthwhile, says Dr. Williamson. "There's fairly wide agreement among scientists that if a family planning program's clientele has an STD problem, the program should try to do something about it." Health providers should consider developing a simple way to evaluate their clients' STD risk in order to determine how much to spend on screening for a particular disease.8 Because STDs are frequently asymptomatic in women, inexpensive screening may not be completely successful. Dependable diagnostic procedures are often costly and may require laboratories or expensive equipment.
One inexpensive method for assessing risk is interviewing clients about their symptoms, also called a "syndrome-based approach." However, in addition to a lack of symptoms in some clients, cultural values may discourage talking openly about intimate relationships and risk behaviors. In Rio de Janeiro, Brazil, FHI researchers were able to encourage frank discussions of STD risk and sexual relations at family planning clinics by using a cartoon soap opera with clients who met in small groups. In private counseling later, the number of clients who were willing to discuss their partners' infidelity and to identify themselves as being at risk for HIV infection increased dramatically compared with their willingness prior to the group sessions, says Dr. Patsy Bailey, public health specialist at FHI's Maternal and Neonatal Health Center. "By talking about it in a group, they allowed themselves to admit it," says Dr. Bailey. "There may have been less denial."
Another question concerning the efficacy of combining STD services with family planning involves the type of clients family planners typically serve. To be most effective in the fight against STDs, health workers may have to target high-risk populations, such as prostitutes and other people with multiple partners. Treating an STD in one high-risk person may avoid transmissions to many others. Family planning clients, however, typically are married women with only one partner. "Nevertheless, family planning providers should not assume their traditional clients do not have a problem," says Dr. Bailey. "The number of women infected with HIV has been increasing, even among groups you wouldn't normally think would be at risk. It seems to justify an intervention."
FHI's Dr. Williamson urges family planning providers to assess the STD risk of clients, even if it is only to ask clients about their risk of infection. "I don't see how you can recommend a contraceptive method if you don't know a client's STD risk," she says. "Yet it isn't being done often enough. It isn't going to be perfect, you have to tailor the questions to each setting, but it doesn't cost anything to do."
Clients should consider their risk of STDs when choosing a method. Family planning programs tend to encourage contraceptives that will be the most effective at preventing pregnancy. Preventing STDs, however, may require the use of latex condoms, which are typically less effective at preventing pregnancy than longer-acting methods since some people do not use barrier methods consistently and correctly. One option is use of "dual methods," using a barrier method to guard against STDs and another method as a contraceptive, such as injectables, the pill, or Norplant.
Maternal health
Family planning plays a major role in preventing maternal mortality and morbidity. "The biggest dent you can make in maternal morbidity is not getting pregnant," says Dr. Judith Fortney, director of FHI's Maternal and Neonatal Health Center. Although there are risks associated with any contraceptive method, these risks are substantially lower than the health risks associated with pregnancy and childbirth. Family planning can also reduce health risks associated with closely spaced pregnancies, high-risk births, and unsafe abortion, concluded a National Academy of Sciences (NAS) panel.9
Maternal mortality declines when women have better access to safe contraception, according to Dr. Fortney. For example, maternal mortality fell by one-third in a rural area of Bangladesh following a community project that increased contraceptive prevalence to 50 percent, compared with 23 percent in a control area.10 Family planning programs may also be appropriate places to counsel women on prenatal care and to encourage breastfeeding.
Although family planning providers rarely see women when they are pregnant or in the midst of childbirth, they could easily give information about prenatal care, pregnancy complications and encourage breastfeeding. They could also provide basic prenatal services, such as iron and iodine supplements, and tetanus toxoid and malaria prophylaxis in infested areas, says Dr. Fortney.
A MotherCare program in Cochabamba, Bolivia increased women's awareness of danger signs in pregnancy by providing such basic information -- a relatively inexpensive service.11 "Forget about weighing patients, forget about nutrition. Every woman knows she should eat more, and she would if she could," says Dr. Fortney. "But if you tell clients symptoms to look out for -- indicators of pregnancy complications, when you really have to go to a hospital, where to go, how to get transportation -- then you'll really be doing something to reduce maternal mortality."
Family planning providers may be able to help pregnant patients plan hospital transportation in advance, she says. A woman's ability to reach obstetric care often depends on help from the community. Since most life-threatening complications occur during labor and delivery, every pregnant women needs rapid access to emergency obstetric care. The majority of maternal deaths and much of chronic morbidity resulting from childbirth are due to lack of timely medical help for pregnancy complications.12
After a woman has given birth, family planning providers can play an important role in counseling about birth spacing and contraceptives. For example, many breastfeeding mothers may not know about the natural contraceptive benefits from breastfeeding, also called the Lactational Amenorrhea Method (LAM). LAM is highly effective during the first six months postpartum as long as a woman has not resumed menstruation and is fully or nearly fully breastfeeding.
Priorities
There are many ways to define reproductive health. Different definitions and priorities are being proposed by women's health advocates and family planning organizations around the globe.
One approach, articulated by FHI's Dr. Hardee and Kathryn Yount of Johns Hopkins University School of Hygiene and Public Health, uses the consensus statement from the United Nation's 1994 International Conference on Population and Development to identify possible services. Good reproductive health, according to the statement, should include freedom from the risk of sexual diseases; the right to regulate one's own fertility with full knowledge of contraceptive choices; and the ability to control sexuality without being discriminated against because of age, marital status, income, or similar considerations.13
Achieving these goals will require a wise use of resources, which may include ways to integrate different reproductive services. For example, family planning programs and other reproductive health projects may be able to share certain services, such as maintaining a central file of patient records. The policies and administrative structure of each country will play a role in determining how different health services are combined.
Client needs and the culture of each community and country should be considered. "To look at reproductive health means looking at all aspects of people's lives," says Dr. Hardee. "Certainly, you need to prioritize. But we think that's something you have to do at a country level."
Another effort to define reproductive health and prioritize goals is being made by NAS, a U.S.-based scientific society. "We don't think we're going to come up with instructions, or a recipe for action," says John Haaga, director of the NAS Committee on Population. "But a lot can be done to clarify priorities that should bring us closer to some answers." In 1996, a NAS study panel may recommend a priority list of reproductive health care services that could be used in many settings, he says.
-- Sarah Keller
Footnotes
Starrs A. Preventing the Tragedy of Maternal Deaths: A Report on the International Safe Motherhood Conference. Nairobi: World Health Organization, 1987. Jacobson JL. Worldwatch Paper 102: Women's Reproductive Health: The Silent Emergency. (Washington: Worldwatch Institute, 1991) 5.
Jacobson.
Tinker A. Safe motherhood: How much does it cost? Unpublished paper. World Bank, 1990.
Pillsbury B, Maynard-Tucker G. USAID Reproductive Health Baseline Survey: A Survey of Projects and Activities Implemented and Planned by USAID Missions and Cooperating Agencies. Washington: USAID, 1994.
Hardee K, Yount K. From Rhetoric to Reality: Delivering Reproductive Health Promises through Integrated Services. Women's Studies Project Working Paper No. 2. Durham: Family Health International, 1995.
Foreit K, Foreit J, Lagos G. Effectiveness and cost-effectiveness of post-partum IUD insertion in Lima, Peru. Int Fam Plann Persp 1993; 19(1): 19.
Family Health International. Proceedings of Understanding STDs and the Public Health Approaches to Their Control: The Appropriate Role of Family Planning Programs. (Durham: FHI, 1994) 2.
FHI, 4.
DeVanzo J, Parnell A, Foege W. Health consequences of contraceptive use and reproductive patterns. Journ Amer Med Assn 1991; 265(20): 2692-96.
Fauveau V. Matlab maternity care program. Unpublished paper. World Bank, 1991. 29.
Pillsbury, D-1.
World Health Organization Maternal Health and Safe Motherhood Programme Division of Family Health. Care of Mother and Baby at the Health Centre: A Practical Guide. (Geneva: WHO, 1994) 9.
International Conference on Population and Development. Programme of Action of the International Conference on Population and Development. New York: United Nations, 1994.
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