Transcript ICPD Paradigm Shift - Rawalpindi Medical College

REPRODUCTIVE HEALTH
A LIFE CYCLE APPROACH
DR ABIDA SULTANA
MBBS.MCPS.FCPS.
Head of Department
Community Medicine
1
2
HADITH of today

No believing man hates his believing wife.
If there is a bad habit in her, there will be
other lovable qualities…(Muslim)
3
OBJECTIVES OF TODAY




To introduce a paradigm shift in the
reproductive health.
To teach the differences between MCH
and reproductive health.
To elaborate the different components of
the package of RH.
To describe the different strategies to
achieve the goals of RH Package.
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OBJECTIVES OF PARADIGM SHIFT:
1.
2.
3.
4.
5.
To introduce the new concept of Paradigm
shift.
To give the rationale of RH concept covering
the entire span of life that is Life cycle
approach.
To explain RIGHTS BASED APPROACH
To elaborate the newer ROLE OF MAN in
child birth.
To differentiate the concept of F.P. services
from RH.
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REPRODUCTIVE HEALTH CARE
The old paradigm (before 1994)
1: FAMILY PLANNING
Unmet need for contraception
2: MATERNAL CARE
Antenatal care
Safe child birth
Post-partum care
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BEFORE 1994 (cont)
3: CHILD HEALTH CARE
Breast feeding promotion
Nutrition
Growth monitoring
Immunization
Sickness care (ORT, ARI, malaria etc)
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ICPD PARADIGM SHIFT
(in 1994)


International Conference on Population
and Development.
1994 Cairo.
To move beyond a narrow focus on
family planning to a more comprehensive
program of integrating population and
health activities that would help
individuals to meet their Reproductive
Health needs.
9
ICPD PARADIGM SHIFT
(cont)

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Provision of family planning services
within a broader type of reproductive
health service
Interrelation of Reproductive Health
with policies to empower women,
strengthen families, stabilize population
growth and eradicate poverty.
Improve women's equality in education,
health and economic opportunities.
10
ICPD PARADIGM SHIFT
(cont)

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
Special focus on fulfilling women’s health
needs, safe guarding their reproductive rights
and involving men as equal partners in meeting
the goal of responsible parenthood.
Shift to Rights Based Approach
Shift away From macro concerns at population
level for reduction in its growth for achievements
of stabilization To micro concern at individual
level for improvement in well being.
11
REPRODUCTIVE HEALTH
“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 or process”
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MATERNAL MORTALITY:
A GLOBAL TRAGEDY
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MATERNAL MORTALITY:
A GLOBAL TRAGEDY
Annually,
585,000
women die of pregnancy
related complications
99% in developing
world

~ 1% in developed
countries

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GLOBAL MATERNAL DEATH WATCH
EVERY MINUTE
Every Minute...
380
women become pregnant
190
women face unplanned or
unwanted pregnancy
110
women experience a
pregnancy related complication
40
women have an unsafe abortion
1
woman dies from a pregnancyrelated complication
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GLOBAL CAUSES OF
MATERNAL MORTALITY
Hemorrhage 24.8%
Infection 14.9%
19.8
24.8
Eclampsia 12.9%
7.9
14.9
12.9
6.9
12.9
Obstructed Labor
6.9%
Unsafe Abortion
12.9%
Other Direct Causes
7.9%
Indirect Causes
19.8%
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What determines
Reproductive Health?
Fetal wellness
 Social context (community, household, family)
_ nutrition, education, housing, income
 Environment
_ Safe water, no toxic exposure
_ Health services access and quality
 Personal efficacy
_ Health competence
_ Health care seeking

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CURRENT DATA OF PAKISTAN
1.
2.
3.
4.
5.
6.

Fertility (per woman)
4.3
Awareness about contraception 96%
Contraceptive prevalence rate
34%
MMR per 100,000 births
350-400
IMR per 1000 births
77
Child MR per 1000 births
103
Source
Pakistan Economic
Survey 2007
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But WHY Do
These
Women Die?
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DETERMINANTS OF
MATERNAL MORTALITY
1. Age at child birth
(Too Early, Too
Late)
2. Parity
(Too Many)
3. Too close pregnancies (Too Close)
4. Family size
5. Malnutrition
6. Poverty
7. Illiteracy
8. Ignorance and prejudices
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DETERMINANTS (cont)
9. Lack of maternity services
10.Shortage of health manpower
11.Delivery by untrained dais
12.Poor environmental sanitation
13.Poor communication and transport
facilities
14.Social customs
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THREE DELAYS MODEL

Delay in decision to seek care
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Delay in reaching care
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Lack of understanding of complications
Acceptance of maternal death
Low status of women
Socio-cultural barriers to seeking care
Mountains, islands, rivers — poor organization
Delay in receiving care



Supplies, personnel
Poorly trained personnel with punitive attitude
Finances
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REPRODUCTIVE HEALTH
PACKAGE
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REPRODUCTIVE HEALTH
PACKAGE
1.
2.
3.
4.
5.
Comprehensive family planning facilities
and care
Safe motherhood, abortions
Infant health care
Adolescents R.H. problems
RTIs/ STDs/ HIV/ AIDS/ HBV/ HCV
prevention, early detection and
management
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REPRODUCTIVE HEALTH
PACKAGE (cont)
6. Infertility
7. Cancer cervix, breast, detection and
management
8. Other RH problems of women
9. Other RH problems of men
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1. COMPREHENSIVE F.P.
SERVICES FOR
a.
b.
c.
d.
e.
f.
Information about availability, advantages,
efficacy, side effect, contraindications of
contraceptives, including natural methods.
Availability and provision of different methods
with safety and quality.
Appropriate screening of clients.
Supportive counseling.
Management of side effects.
Follow-up.
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2. SAFE MOTHERHOOD
a.
b.
c.
d.
e.
f.
Antenatal registration and care.
Treatment of existing conditions (e.g.
anemia, malaria).
Advice regarding nutrition and diet.
Iron/folate supplementation.
Essential obstetric care (EOC).
Clean and safe (atraumatic) delivery.
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SAFE MOTHERHOOD
(cont)
g. Early detection and management of
postpartum complications.
h. Prevention and management of
urinary and rectal fistulae and
prolapse.
i. Genetic counseling.
j. Blood test during pregnancy for Rh
incompatibility.
k. Tetanus immunization .
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PRE / POST ABORTION
CARE FOR COMPLICATIONS
1.
2.
3.
Create awareness about dangers of
abortion.
Detection and early management of
complications of abortion.
Counseling to post abortion cases
including advice regarding F.P. to
avoid recurrence.
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3. INFANT HEALTH CARE
a.
b.
c.
d.
e.
f.
g.
h.
Resuscitation of the newborn.
Early and exclusive breast feeding.
Management of infection (ophthalmia
neonatorum and cord infections).
Congenital abnormalities.
L.B.W and malnutrition management.
Weaning.
Safe and aseptic circumcision.
Immunization.
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4. MANAGEMENT OF RH
PROBLEMS OF ADOLESCENTS
1.
2.
3.
4.
Education of normal physiological changes at
puberty.
Management of problems as dysmenorrhea
hirsutism, sexual abuse, vaginal discharge etc.
Personal hygiene.
Detection and management of congenital
abnormalities, imperforate hymen, early /
delayed menarche.
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5. PREVENTION AND MANAGEMENT OF
RTIs/STDs AND HIV/AIDS
a. Information for prevention.
b. Screening and management.
6. MANAGEMENT OF INFERTILITY
a. Information for prevention.
b. Management of allied problems.
c.
Investigations and early treatment.
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7. DETECTION OF CANCER:

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
BREAST
Inform and train for self examination.
Early detection and management.
Screening for breast lumps.
Supporting, counseling, rehabilitation.
CERVICAL
Pap smear.
Early detection and management.
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8. MANAGEMENT OF OTHER RH
PROBLEMS OF WOMEN
1.
2.
3.
4.
Awareness and management of pre and
menopausal syndrome.
Detection and management of
menopause related deficiencies.
Management of sexual dysfunction as
loss of libido and dyspareunia.
Management of post menopausal
circulatory diseases.
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9. MANAGEMENT OF RH
RELATED PROBLEMS OF MEN
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Adolescent health
Counseling, motivation for F.P. RH rights of
women and responsible parenthood.
Male involvement in antenatal, natal and post
natal care of woman.
Counseling on main sexual problems and
dysfunctions.
Counseling for prevention of RTIs/STDs and
treatment of infertility.
Detection and management of cancer and related
problems.
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LIFE CYCLE APPROACH TO
REPRODUCTIVE HEALTH
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LIFE CYCLE APPROACH TO
REPRODUCTIVE HEALTH

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Infancy and childhood (0-9yrs)
Adolescents (10-19 yrs)
Reproductive years (20-44 yrs)
Post reproductive years (45+ yrs)
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LIFE CYCLE APPROACH TO DEFINE
WOMEN'S LIFE TIME
HEALTH PROBLEMS
38
Infancy & childhood (0-9 yrs)

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Sex selection
Genital mutilation
Discriminatory nutrition
Discriminatory health care
Gender ID /modeling
Behavior
Aggression
Education
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Adolescents (10-19 yrs)
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Early child bearing
Abortion
STIs/AIDs
Under nutrition- macro &micro
Rising trend of substance abuse
Acne
Physiological changes in the body
Secondary sex characteristics
Aggression
Violence/abuse
Gender discrimination
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Reproductive Years (20-44 yrs)
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
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Unplanned pregnancy
STIs/AIDs
Abortion
Pregnancy complications
Malnutrition
Pregnancy
Child bearing and rearing
Contraception
Abuse and violence
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Post-Reproductive years (45 + yrs)
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Cardio-vascular diseases
Gynecological cancers
Osteoporosis
Osteoarthritis
Diabetes
Cancers
Sexual dysfunction
Sub fertility/infertility
STD/HIV
Menopause
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RIGHT BASED APPROACH
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THE RIGHT
•
•
•
•
TO attain the highest standard of sexual and
reproductive health throughout the life cycle.
For reproductive self determination including:
* Right to voluntary choice in marriage
* Right to decide freely the number, timings
and spacing of children and to have means
to do so.
OF Sexual and Reproductive Security including
freedom from sexual violence and coercion.
OF Equality and Equity for men and women in
all spheres of life.
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ADDITIONAL
ISSUES
with the new paradigm
46
Reproductive health care
Addition with the new paradigm
1. GENDER DISCRIMINATION
 Sex selective abortions
 Son preference for food allocation, health care,
education, etc
2. VIOLENCE AGAINST WOMEN
 Child pornography
 Commercial sex
 Female genital mutilation
 Spouse abuse
 Rape, incest
(cont)
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Reproductive health care
Addition with the new paradigm
3. ADOLESCENT SEXUALITY
4. REPRODUCTIVE RIGHTS regarding
marriage and childbearing
5. GENDER EQUITY AND EQUALITY
6. UNINTENDED PREGNANCY
* Emergency contraception
* Safe abortion
(cont)
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Reproductive health care
Addition with the new paradigm
7. CHRONIC COMPLICATIONS OF PREGNANCY
AND CHILDBIRTH
8. SEXUALLY TRANSMITTED DISEASES
* Acute infections
* Chronic complication, e.g.
infertility
cervical cancer
9. HIV / AIDS
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REPRODUCTIVE HEALTH
INTERVENTIONS
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REPRODUCTIVE HEALTH
INTERVENTIONS
FOR FEMALES
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Preconception care (family planning)
Family life education
Antenatal care and nutrition
Delivery and postnatal care
Reproductive Tract Infection (RTI) Care
Sexual Health (STI, HIV / AIDS)
Reproductive cancer treatment
Other reproductive function
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REPRODUCTIVE HEALTH
INTERVENTIONS
FOR MALES




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

Preconception care (family planning)
Adolescent health
Male involvement in Antenatal care,
Delivery and Postnatal care of woman
Reproductive Tract Infection (RTI) Care
Sexual Health (STI, HIV / AIDS)
Reproductive cancer treatment
Other reproductive functions
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HARMFUL TRADITIONAL
REPRODUCTIVE HEALTH
PRACTICES
53

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Early marriage
Female Genital Cutting/Mutilation (FGM)
“Dry sex” practices
Dietary and other restrictions during
pregnancy
Heavy work during pregnancy
Withholding colostrums from newborn
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GENDER AND
REPRODUCTIVE HEALTH
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SEX
Biological.
 Refers to visible differences in
genetalia.
 Related differences in procreative
functions.
 Constant, can not be changed.

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GENDER
Socio-economically determined.
 A culture.
 Refers to masculine and feminine
qualities, behavior patterns, roles
and responsibilities etc.
 A variable, not constant.

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GENDER AND LIFE CYCLE
OF PAKISTANI WOMAN
A Summary
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
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Before conception: sex selective
technology.
In uterus: sex selective abortion.
New born: female infanticide.
Infancy: benign neglect.
Childhood: poor health care seeking/
access.
Adolescence. lack of education/ illiteracy/
sexual violence.
Adulthood: reproductive morbidity/
mortality, dowry deaths.
Old age.
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MILLENNIUM DEVELOPMENT
GOALS
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GOAL 1: Eradicate extreme
poverty and hunger


Reduce by half the proportion of people
living on less than a dollar a day.
Reduce by half the proportion of people
who suffer from hunger.
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Goal 2: Achieve universal primary
education

Ensure that all boys and girls complete a
full course of primary education.
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Goal 3: Promote gender equality
and empower women

Eliminate gender disparity in primary and
secondary education preferably by 2005,
and at all levels by 2015.
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Goal 4: Reduce Child mortality

Reduce by two thirds the mortality rate
among children under five.
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Goal 5: Improve maternal health

Reduce by two three quarters the
maternal mortality ratio.
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Goal 6: Combat HIV / AIDS, Malaria
and other diseases


Halt and begin to reverse the spread of
HIV/AIDS
Halt and begin to reverse the incidence of
malaria and other major diseases.
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QUALITY OF CARE
67


1.
2.
3.
4.
5.
6.
The way individuals and clients are
treated by the system providing
services.
Six elements.
Choice of methods of contraception.
Information given to clients.
Technical competence. Protocol. Clinical
techniques. Meticulous asepsis.
Interpersonal relations, between provider
and client.
Mechanism to encourage continuity.
Appropriate constellation of services.
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FACTORS INFLUENCING
PROVISION OF
RH SERVICES
69
1.
2.
3.
4.
Number of service delivery
points.
Geographical, physical and
social accessibility.
Proper advertisement of
services.
Quality of care.
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QUALITY OF CARE

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Opening and closing timings.
General cleanliness.
Maintenance of privacy.
Proper waiting area.
Trained staff.
Availability of range of services (medicine/
equipments).
Client/ provider interaction.
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RH SERVICES OUTLETS IN
PAKISTAN
72
Public sector programs
1. Community Based Services.
National Program for Family Planning
and PHC.
72,000 Lady Health Workers, one for
1000 women.
21,304 trained midwives.
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Public sector programs
2.
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
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Family Based Services.
MCH Centers. 906 in number. Run by LHV.
BHUs. 5,301. one for 5-10,000 people.
Two inpatient beds. Medical officer. Staff
of 10.
RHCs. 552. one for 25-50,000 people. Staff
of 30.Ten to twenty beds.
THQs. One for 100-300,000 people.
DHQs. One for 1-2 million people.
Specialized institutions/ Teaching
hospitals.
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PRIVATE SECTOR PROGRAMS.
1. Qualified doctors.
GP (general practitioners)
Specialists.
2. Unqualified practitioners (quacks).
3. Hakeems.
4. Homeopaths.
5. Tibb or Unani medicine.
6. NGOs as Rozan and Sahil in Punjab, Aahung in
Sindh.
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CLIENT/ PROVIDER
INTERACTION
76
SAHR
1.
2.
3.
4.
SALUTATION; greet/ ice breaking,
assure client, show patience.
ASSESS; decision making about
other RH problems of client.
HELP; encourage client to speak,
inform about options, cost, time etc.
REASSURE; request client to repeat
her solution. reassure about
solution.
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