REPRODUCTIVE HEALTH

Reproductive health is a concept that came to prominence in international discourse about population issues in the 1990s, especially as a result of the preparatory process leading to the International Conference on Population and Development (ICPD) held in Cairo in 1994. It is defined in Chapter 7, paragraph 2 of the ICPD Programme of Action as follows:

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. Reproductive health therefore 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. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to 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. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being 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 counseling and care related to reproduction and sexually transmitted diseases.

From Birth Control to Reproductive Health

The evolution of language referring to fertility policy since the 1950s, from "birth control" to "family planning" to "reproductive health," represents a paradigm shift in theory, policy, and practice. When concerns about the consequences of delayed fertility decline in the demographic transition in the developing world originally emerged, the major focus was on the economic implications of rapid population growth. Logically, this necessitated a better understanding of the factors influencing fertility and reproduction. For example, priority was placed on mapping and measuring the proximate determinants of fertility, and the socioeconomic characteristics of women that influence the proximate determinants. Interest in reproduction in general, and fertility regulation in particular, has gradually evolved into attention to reproductive health. A variety of actors, ranging from demographers to women's health advocates, worked together in the early l990s to propose this new, broader approach. They intended to promote population and development policies and programs that were centered on individual rights, health, and well-being.

The World Health Organization (WHO) defines health as a "state of complete physical, mental and social well-being." The ICPD applied this concept of health to reproduction. WHO promotes, and sets standards for, scientific analysis of reproductive health. Estimates of the "global burden of reproductive ill-health" clearly signal that that burden affects women more than men. (See Table 1) For women of childbearing age in developing countries, the burden of reproductive ill-health is far greater than the disease burden from such important diseases as tuberculosis and respiratory infections. Among women aged 15 to 44 in developing countries, reproductive ill-health is estimated to account for 36 percent of the total disease burden, compared with 12 percent for men.

As advocates of the concept emphasize, reproductive health services are not limited to family planning services, nor is their clientele limited to women in unions. Programs delivering family planning services could be organized as categorical programs; this is more difficult for reproductive health services, which require a broader array of facilities. Reproductive health is not solely a health issue. The concept includes such factors as gender-based violence, power dynamics in sexual relationships, and individuals' subjective assessment and perception of risks involved in contraceptive practice. As stated in a follow-up report on ICPD (ICPD+5), "There is a continuing need to include social, cultural, economic and behavioural dimensions in the planning and implementation of reproductive health policies and programmes. This requires the involvement of many other sectors in a partnership to remove barriers to access and create a more enabling environment" (United Nations Population Fund 1999, paragraph 65).

Reproductive Health Services

The programmatic implications of the goal of improving reproductive health, over and above the provision of contraceptive services, include prevention and treatment of reproductive tract infections, sexually transmitted diseases, including HIV, and reproductive system cancers; counseling or treatment of infertility; pregnancy and delivery care; access to safe, legal abortion; and information on sexuality and sexual dysfunction.

The concept of reproductive health provides a framework to guide program implementation strategies and performance indicators. It emphasizes quality of care for the individual, often neglected in older, target-oriented family planning programs. For example, a client-provider interaction concerned with choosing an appropriate contraceptive can be used for family planning counseling as traditionally practiced (mostly one-way, didactic communication from an authority figure to a passive acceptor about medical aspects of contraception), or it can involve true two-way dialogue, with the provider seeing the client as a partner in solving health problems. The latter model of reproductive health care includes exploring topics such as sexual practices and risks, as well as the gender and power dynamics that affect those risks.

TABLE 1

The Future of Reproductive Health

Future improvements in reproductive health call for more research, drawing on both social science methods and "operations research" on the effectiveness and costs of reproductive health interventions. Special attention needs to be paid to promoting evidence-based reproductive health care in developing countries. The WHO and other international agencies have made a major commitment in this area. The WHO Reproductive Health Library (RHL) offers analyses to help ensure that resource allocations and current health care practices are based on scientifically solid and up-to-date information. The RHL aims "not only to prevent the introduction of unsubstantiated health care practices into programmes but also to replace the practices that have been demonstrated to be ineffective or harmful with those based on best available evidence" (Villar et al. 2001). Stronger assessments of the economic value of reproductive health interventions are also needed, so that investments in reproductive health are given their proper priority in health sector reform.

Beyond research, the ICPD and ICPD+5 documents include numerous recommendations for governments, United Nations agencies, donors, and other actors concerning reproductive health. A roadmap for progress has been laid out, ranging from specific "benchmark indicators" in health to suggested changes in policies and resource allocation. The recommendations cover not only specific health topics such as maternal mortality, but also the reproductive health needs of population groups such as adolescents and men, while acknowledging the priority that should be accorded to women and girls.

Commitment to implementing the reproductive health approach requires a clear understanding of how the thinking underlying it differs from the once prevalent "population control" mentality, and the programmatic and policy changes implied by this paradigm shift. The Fourth World Conference on Women summed up the links among reproductive health, human rights, gender equity, and sexuality in its Platform for Action (United Nations 1995, paragraph 96):

The human rights of women include their right 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. Equal relationships between women and men in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behaviour and its consequences.

BIBLIOGRAPHY

Bongaarts, John, and Robert G. Potter. 1983. Fertility, Biology, and Behavior: An Analysis of the Proximate Determinants. New York: Academic Press.

Campbell, Oona, John Cleland, Martine Collumbien, and Karen Southwick. 1999. Social Science Methods for Research on Reproductive Health. Geneva: World Health Organization.

Davis, Kingsley, and Judith Blake. 1956. "Social Structure and Fertility: An Analytic Framework." Economic Development and Cultural Change 4(3): 211–235.

Germain, Adrienne, Sia Nowrojee, and Hnin Hnin Pyne. 1994. "Setting a New Agenda: Sexual and Reproductive Health and Rights." In Population Policies Reconsidered: Health, Empowerment, and Rights, ed. Gita Sen, Adrienne Germain, Lincoln C. Chen. Boston: Harvard Center for Population and Development Studies.

Helzner, Judith F. 2002. "Transforming Family Planning Services in the Latin American and Caribbean Region." Studies in Family Planning 33(1): 49–60.

Jain, Anrudh, and Judith Bruce. 1994. "A Reproductive Health Approach to the Objectives and Assessment of Family Planning Programs." In Population Policies Reconsidered: Health, Empowerment, and Rights, ed. Gita Sen, Adrienne Germain, and Lincoln C. Chen. Boston: Harvard Center for Population and Development Studies.

Villar, José, Metin Gülmezoglu, Jitendra Khanna, Guillermo Carroli, Justus Hofmeyr, Ken Schulz, and Pisake Lumbiganon. 2001. "Evidence-based Reproductive Health in Developing Countries." WHO Reproductive Health Library 4.

INTERNET RESOURCES.

Health, Action, Empowerment, Rights & Accountability (HERA). 1998. "Action Sheet: Reproductive Rights and Reproductive Health." <http://www.iwhc.org/uploads/HERAactionsheeteng%2Epdf>.

United Nations. 1995. "Beijing Declaration Platform for Action, Fourth World Conference on Women (FWCW)." <http://gopher://gopher.undp.org/00/undocs/gad/A/CONF.177/95_11/20>.

United Nations Population Fund. 1994. "International Conference on Population and Development (ICPD), Programme of Action." <http://www.unfpa.org/ICPD/reports%26doc/icpdpoae.html>.

——. 1999. "International Conference on Population and Development ICPD+5, Implementation of the Programme of Action." <http://www.unfpa.org/icpd/icpdmain.htm>.

World Development Report. 1993. "Investing in Health." <http://publications.worldbank.org/ecommerce/catalog/product?item_id=194651>.

World Health Organization. 1997. "The global burden of reproductive ill-health." Progress in Human Reproduction 42: 2–3. <http://www.who.int/hrp/progress/42/prog42.pdf>.