The Challenge Ahead
Virtually nowhere in the Third World are contraceptives available to all the women - and men - who want them. Some argue, therefore, that programmatic priority should continue to emphasize contraceptive supply and acceptance. It is not enough simply to make commodities available, however. To serve women well, and to reduce attacks from both the Right and the Left, contraceptives must be made available in settings where quality of services, counseling, choices among methods, and respect for reproductive freedom are prominent.At the urging of women's health advocates and others, population professionals now recognize that the earlier focus on contraceptive acceptance rates needs to be broadened. Women in the Third World are calling for more comprehensive services that provide them with reproductive choices and that reduce ill health and death resulting from their sexual and reproductive roles. The central objectives of "reproductive health" programming are therefore to enable Third World women to:
- Regulate their own fertility safely and effectively by conceiving when desired, by terminating unwanted pregnancies, and by carrying wanted pregnancies to term;
- Remain free of disease, disability, or danger of death due to reproduction and sexuality;
- Bear and raise healthy children.
Reproductive health approaches seek to provide comprehensive services, emphasize high quality care, and are premised on fully informed choices. They build on the base established by family planning, MCH, child survival and related programs. They seek modifications in current programs to make women's well-being and reproductive choices the central objectives. Demographic goals are important, but they are not primary.
What is Reproductive Health Care?
It is comprehensive, providing:
- Education on sexuality and hygiene;
- Education, screening and treatment for reproductive tract infections, and gynecological problems resulting from sexuality, age, multiple births and birth trauma;
- Counseling about sexuality, contraception, abortion, infertility, infection and disease;
- Infertility prevention and treatment;
- Choices among contraceptive methods, with systematic attention to contraceptive safety;
- Safe menstrual regulation and abortion for contraceptive failure or non-use;
- Prenatal care, supervised delivery and postpartum care;
- Infant and child health services.
It is high quality:
- Treating clients with respect and compassion;
- Following them up.
It is premised on informed choice:
- Providing full information;
- Encouraging continued use of services, rather than just initial acceptance.
How Can it be Implemented?By building on existing programs through:
- Revised staff training content and procedures;
- Intensified staff supervision and modified reward systems;
- Additional services to ensure choices, safety and effectiveness.
By expanding available resources through:
- Collaboration among programs;
- Public education and advocacy to broaden political support.
Reproductive Health Care in Indonesia
In Indonesia family planning is encouraged by the government, but limited to dispensing contraceptives, with emphasis on oral contraceptives, the IUD (inter-uterine device), Norplant (capsules containing hormones implanted under a women's skin to prevent conception for up to 5 years) and, more recently, condoms. Approximately 55 percent of couples nationwide practice contraception, and the government's infrastructure for service delivery is comparatively strong.The Indonesian Planned Parenthood Association (IPPA), seeking means to address important gaps, is experimenting with an approach to high quality, comprehensive reproductive health care in 7 of its approximately 50 clinics. The approach includes:
- Counseling to help women manage sexuality, help them choose among contraceptive methods, and switch methods rather than discontinue use;
- Design and testing of procedures for routine screening and treatment of reproductive tract infections;
- Careful follow-up of IVD and Norplant users;
- Improved systems of client data collection and analysis;
- Development of informational materials for clients and staff;
- Support and services for women who have unwanted pregnancies.
Such approaches imply a long-term strategy of collaboration among programs now competing for scarce resources. If this collaboration is rooted in a common, humane concern for girls and women in Third World countries, support for international population assistance is likely to be strengthened and criticisms deflected. Although currently accorded relatively low priority in the delivery of services, several basic means of achieving the objectives of reproductive health care are already widely recognized as beneficial, such as:
- Improved program and clinic management;
- Improved logistical systems to assure a reliable flow of supplies;
- Expanded research to develop safer, more effective contraceptives for both women and men.
In addition, family planning and health programs need substantial modifications. For example:
- Training materials for staff need to emphasize contraceptive choices and address other aspects of reproductive health and sexuality.
- Similar informational materials need to be developed for women.
- Reward systems for staff and program evaluation criteria need to give more weight to respectful treatment of women and to continuing use of services rather than simply initial acceptance.
- Record systems need to be modified so that each woman, not just the particular service or contraceptive method delivered, can be followed over time .
- Much more needs to be done to encourage men to take responsibility for contraception and safe sexuality, and to support their partners in doing so.
- Services need to he expanded to encompass currently neglected problems such as reproductive tract infections, infertility, safe abortion, and violence.
Bangladesh Women's Health Coalition:
In Bangladesh, maternal, infant, and child mortality rates are among the highest in the world. Less than 30 percent of reproductive age couples as yet have effective access to modern contraception. Broader provision of MCH services, enhanced contraceptive choices, and continuity and effectiveness of contraceptive practice are major challenges.
A Decade of ExperienceThe Bangladesh Women's Health Coalition (BWHC) provides high quality, comprehensive reproductive health care at reasonable cost. Founded in 1980, the BWHC operates six clinics in low-income neighborhoods in urban and rural Bangladesh and serves 75,000 women and their children annually. Services include counseling, contraception, menstrual regulation (simple, vacuum aspiration of the uterus, usually performed within ten weeks after the last menstrual period), basic child and women's health care, prenatal and post partum care.
The primary service providers, almost all women, are recruited from the community for their interest in serving other women and for their professional skills. They have up to ten years of formal education, and eighteen months of government training, are supervised by physicians and supported by nurses' aides and administrative staff, all of whom are trained to provide health and family planning information to clients. Because the BWHC's policy is to treat clients with kindness and respect, and provide them with the full information necessary to make choices about their health and family planning needs, salary increases and promotion depend on providing quality care, not only quantity.
Each client has a registration card and file that are used every time she or her children visit the clinic, so that staff can keep track of her and her family. A counselor answers all the client's questions to ascertain that she has full information and carefully considers her options and choices. Once the client has decided on the services she wants, staff accompany her through the clinic to reassure and comfort her, to remind her how to care for herself so that no complications develop, and to tell her when to return for a follow-up visit.
Low overhead, high volume, and multiple services make BWHC's high quality care inexpensive. For example, the cost to provide a woman menstrual regulation, contraceptive information and services, and follow-up care is US $6.00. BWHC clinics, however, can serve only a small fraction of the women in need. So the Coalition also trains others, especially government health and family planning workers.
In most of the Third World, competition for scarce human and financial resources is intense and political commitment to women's reproductive health not yet strong. This may mean that comprehensive reproductive health programs will not be considered feasible in the short run. But competing or conflicting claims require explicit assessment, not unexamined assumption, to determine the likely benefits of alternative resource allocations. For example, maternal deaths could be reduced by as much as 25-50 percent in the next decade by even a modest increase in health service coverage for childbirth and for safe medical termination of pregnancy. Expanding the number of contraceptive choices available would be cost-effective by encouraging sustained use rather than short-term acceptance.
Conclusion
Woman-centered reproductive health approaches that emphasize options and quality of care -- widely accepted as a woman's right in the United States -- could appeal to more constituencies than have conventional family planning programs to date. These several constituencies include, among others:
- Child survival and primary health care professionals, as well as women's health advocates, who recognize family planning as an essential health service for women and children;
- Those concerned with "women in development," who seek to enable women to make choices about their lives and to more effectively and safely manage their productive, reproductive, and household responsibilities;
- Proponents of social justice and human rights who recognize that women cannot exercise their basic rights fully unless they have effective access to reproductive health care and choice;
- Population professionals who want not only to increase the number of contraceptive users but also to encourage longer continuation rates for both demographic and health effects;
- Other professionals and organizations, the U.S. Congress, and a wider public concerned about economic development and the reduction of poverty in the Third World.
To date these various constituencies have at best ignored each other and at worst come into conflict or competition because they have different perceptions about the benefits or drawbacks of "population control." Reproductive health approaches, with women's health and reproductive choices as their central concern, would provide a firmer base for coalition building. Such collaboration could lead to sustained and preferably increased resource allocation, especially in the U.S. foreign assistance program.
"Population" is a fundamentally human problem. The solutions must be both humane and responsive to the complexities of people's behavior. For both humanitarian and political reasons, those concerned about population growth need also to reaffirm their commitment to individual well-being. That commitment can be enacted by making reproductive choices possible, by modifying program approaches to emphasize quality of care, and by recognizing and seeking to meet women's multiple reproductive health needs. The potential scope for innovation is broad. In setting program priorities, it is essential to recognize that the woman is important in her own right, as well as the key actor in fertility regulation and in infant and child health. Her needs, not just those of her children, family, and society, must be central. Alliances for this purpose will be to the benefit of all.
An International Call for Action
Two hundred women's health advocates and health professionals from 34 countries, primarily in the Third World, attended The Christopher Tietze International Symposium "Women's Health in the Third World: The Impact of Unwanted Pregnancy," held in Brazil in October, 1988, and sponsored by IWHC. The Symposium issued the following statement:Reproductive rights are fundamental to women's achievement of a just status in society. Reproductive health care services are essential for the exercise of these rights. Achieving total health for women demands their full participation in defining their health needs, and in designing and implementing health policies.
The overwhelming medical evidence presented at The Christopher Tietze International Symposium clearly shows the adverse consequences of poor reproductive health care services for women in general, and for Third World women in particular. These consequences include extremely high levels of maternal mortality and morbidity, due importantly to clandestine abortion where abortion is legally restricted, and to the lack of adequate abortion services where legal. The situation is exacerbated by the disparity in health resources between and within countries.
We deplore the current restrictive policies and pressures, dictated by cultural and religious beliefs and political interests, that are being applied globally and locally to reduce women's access to health services and to reproductive choices -- in particular the right to terminate an unwanted pregnancy safely.
The Symposium calls on governments to acknowledge the appalling wastage of women's lives; to eliminate legal constraints on voluntary abortion; and to generate necessary health policies and resource allocations.
Efforts should be made to increase the health profession's sensitivity and commitment to women's need for and right to high quality reproductive health care.
Our mutually held commitment to women's reproductive health and rights, premised on fundamental ethical principles of justice, liberty and tolerance, provides the basis for a continuing alliance of doctors, health care providers, women's groups and activists, and women and men from North and South alike.
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