Transcript Folie 1

Reproductive Health Challenges
amongst The University of
Nairobi youth
Dr Carol Odula-Obonyo
M.Med(Ob/Gyn), F.U.O.N.
February 28th 2015
School of Medicine
College of Health Sciences
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Outline
• Definitions
• Susceptibility to sexual advances-STI’s, HIV,
abortion
• Youth friendly services
• Lessons learnt
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WHO's definition of health
• Health is as a state of complete physical,
mental and social well-being, and not merely
the absence of disease or infirmity
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Reproductive health
• Health is as a state of complete physical,
mental and social well-being, and not merely
the absence of disease or infirmity, reproductive
health addresses the reproductive processes,
functions and system at all stages of life.
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Implication
• Reproductive health, therefore, implies that
people are able to have a responsible,
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.
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Continued
Implicit in this are the right of men and women
to be informed of and to have access to safe,
effective, affordable and acceptable methods
of fertility regulation of their choice, and the
right of access to appropriate health care
services that will enable couples/women to go
safely through pregnancy and childbirth and
provide couples with the best chance of having
a healthy infant
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Reproductive health -a state of complete physical,
mental and social well-being, and not merely the
absence of disease or infirmity, reproductive health,
or sexual health/hygiene, addresses the reproductive
processes, functions and system at all stages of life.
Reproductive health, therefore, implies that people are
able to have a responsible, satisfying and safer sex
life and that they have the capability to reproduce and
the freedom to decide if, when and how often to do so.
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Meaning of “The Right to Health”
• Every human being is entitled to the enjoyment
of the highest attainable standards of health
conducive to living a life of dignity.
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• Sexual health-"Sexual health is a state of
physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the
absence of disease, dysfunction or infirmity.
Sexual health requires a positive and respectful
approach to sexuality and sexual relationships,
as well as the possibility of having pleasurable
and safe sexual experiences, free of coercion,
discrimination and violence. For sexual health
to be attained and maintained, the sexual rights
of all persons must be respected, protected and
fulfilled."
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Definition of Sexual Health
• Sexual Health includes the ability to enjoy
mutually fulfilling sexual relationships, freedom
from sexual abuse, coercion, or harassment,
safety from sexually transmitted diseases, and
success in achieving or in preventing
pregnancy.
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Maternal Health
 Motherhood is meant to be a positive and
fulfilling experience
 For many women it is however associated with
suffering, ill-health and even death
 Good news: the deaths and suffering are totally
preventable
 Bad news: the deaths and suffering continue
year after year
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Maternal death
"the death of a woman while pregnant or within
42 days of termination of pregnancy,
irrespective of the duration and site of the
pregnancy, from any cause related to or
aggravated by the pregnancy or its
management but not from accidental or
incidental causes."
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Direct Maternal Death
• Results from obstetric complications of
pregnancy, labour and puerperium and from
interventions or any after effects of these
events e.g. death from PPH.
• The “BIG FIVE” causes of direct maternal
deaths are: bleeding (haemorrhage), unsafe
abortion, hi blood pressure complications
(PET/Eclampsia), obstructed labour and
1infection (sepsis)
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Indirect maternal deaths
• Are deaths that result from worsening of
existing maternal condition by pregnancy or
delivery e.g.: Malaria, diabetes, sickle cell
disease, HIV, cardiac disease
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Maternal Mortality Rate
• The number of maternal deaths per year for
every 100,000 women of repro age (WRA),
15-49 years
• This measure reflects both the risk of death among
pregnant and recently pregnant women, and the
proportion of all women who become pregnant in a
given year. It therefore can be reduced either by
reducing obstetric risk (as is true for the ratio, above)
and/or by reducing the number of pregnancies
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Maternal Mortality Ratio
• Is the number of maternal deaths per 100,000
live births
• This measure indicates the risk of maternal
death among pregnant and recently pregnant
women. It is a measure of obstetric risk and a
reflection of a woman’s basic health status, her
access to health care, and the quality of service
that she receives
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Life Time Risk of Maternal Death
• This measure reflects the probability of
maternal death faced by an average woman
cumulated over her entire reproductive lifespan.
• Like the maternal mortality rate, it reflects both
a woman’s risk of dying from maternal death, as
well as her risk of becoming pregnant in the
course of a reproductive lifetime
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A look at our statistics
• Total population 38-40 million
• Very youthful – pyramid with a very wide base
• Proportion of births under skilled care 42%
• Maternal mortality ratio 488/100,000
• CPR 39% modern, total 46% KDHS 2008-9
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A look at our statistics contd….
 Total fertility rate- 4.6
 Unplanned pregnancies- 17%- unwanted, 26%mistimed
 Contraceptive use- 46%
 Unmet need for contraception among married
women- 25%
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 Maternal
mortality rate- 488/100,000
Statistics
 55% population less than 19 years
 Average age for first sexual experience/debut is 15
years
 1/3 of pop between 13 and 19
 40 % of women who die of abortion are below age 20
 80% of young people have had sex by age 20
 Almost 50% of adolescents begin childbearing before
age 20
 Young people disproportionately represented among
abortion-seekers many of whom endure the risk of
unsafe clandestine procedures
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Beware!!!!!!!
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Definitions
• Youth-Age 15 to 24 years
• Youth friendly services-Those that attract young
people, respond to their needs and retain
clients for continuing care
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Investing in our youth
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Youth all over the world……… “..nothing for us
without us..”
Thy have a right to know, to get involved and to
access the services.
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•
•
•
•
Issues at a glance
Half of the world’s population <25
30% are between 10-24
20% are between 10 and 19
87% live in low income countries
• Africa- below the age of 25 years constitute about
60% of our population:- 10-24yr = 33%
• Many of them are married
Why have we forgotten their contraceptive and other RH
needs???
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Factors that influence young people’s
reproductive health
Institutions
Young
Reproductive
people’s
decisionFertility
taking and
•Abortion
reproductive
•Morbidity
health
-STI/HIV
behaviours
-RTI
-Anaemia
Family
Peers
Individual
Partners
•Mortality
• Nutritional
status
Household
Communities
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health outcom
At what age…in Kenya?
• Menarche……………
• Sexual debut…………..
• First birth………………
• Marriage………….
• Drinking ………………………
• Smoking………………….
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Sexual activity and childbearingyoung women
% women who by
age 20……….
Sub
Saharan
Africa
Asia
N.Amer,
Mid east
L.Amer
5 HI
Caribbea Countries
77%
Have had 1st sex
-Before marriage

-Within marriage

Have had a child
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83%
Not avail
56%
67%
38%
Not avail
28%
45%
48%
28%
10%
55%
32%
34%
17%
Examples
• Nicaragua-First birth before age 20 so one of the
highest adolescant fertility rates in the world.
• Cambodia-1st birth at 20-22.
• South Africa-1 in 3 girls child <20
• Adolescent women’s contraceptive use is less
consistent than that of adult women with a much
higher failure
rate.
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Problem area
• Differences -urban/rural, in-school/out-ofschool, girls/boys influence access to health
care and sources of education, information and
support.
• Risk factors - early sexual initiation, substance
abuse, depression, ignorance about
contraception.
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Are youth more vulnerable?
• Sexual abuse-rape, defilement, cross generational sex
•
Lack of youth friendly services
• Early sexual behaviour is condemned &
pregnancy perceived shame full- fear to seek safe
abortion services where they exist.
• Limited financial resources
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CONTRACEPTION
• This is prevention of a male and female gamete
to meet and hence preventing a pregnancy
from occurring and refers to enjoyment of sex
without one conceiving
• This is different from family planning which
refers to a couple having the number of children
that you desire and can be able to support, by
either using natural or artificial means
• The right to contraception of choice is protected
under several agreements and treaties Kenya
Why contraception?
• Prevents unplanned pregnancies and can give
one the freedom to choose the right time for
parenthood
• Condoms protect one from HIV/Aids and
sexually transmitted infections (STIs)
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Ask yourself:
“Why do I need
Contraception?”
Answer is simple: to control
your natural fertility. If a
woman didn’t use
contraception
she would have up to 15
pregnancies in her life time!.
Contraception protects us
and allows us to enjoy a very
pleasurable and fun part of
living- sex.
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CPR IN VARIOUS REGIONS
CPR IN VARIOUS PROVINCES
70
67
55
60
52
CPR(%)
50
47
42
40
37
34
30
20
4
10
0
Central
Nairobi
Eastern
Western
Rift valley
PROVINCE
Nyanza
Coast
North
eastern
Reasons for not using Contraceptives
 Little knowledge on contraceptives within the
community
 Cultural barriers: Myths & misconceptions
 Health system problems:
 Cost
 Lack of training for providers
 Lack of supplies
*All these lead to unwanted pregnancy
YP and condom use
• “Blind trust”- YP tend to trust their partners
easily and blindly. Condoms may be used during the
1st, 2nd and 3rd sexual contacts, thereafter be
abandoned without HCT
• Myths and beliefs- condoms are association
with promiscuity; not 100 percent effective; cheaper
are not good (GoK type), no sexual satisfaction
• Condoms have holes:
• Boy-girl relationship and courting: may
make condom use unfavorable: sexual activity is not
a planned occurrence
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YP and condom use
• Girls are particular on the type / brand of
condoms use: generally expect the boy to
meet the cost
• Sexual coercion as part of courting, seen
as normal, hence condoms may not be
used in such cases: or incase it’s the first
sexual contact
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Not in a sexual relationship????????
Arm yourself with all
your choices.
Goal
• To have children by choice, not by chance
Contraception
• Against conception
• Use of contraceptives enables couples achieve
the objectives of family planning-planning when
to start, how to space, & when to stop giving
birth.
Family Planning
A comprehensive term meaning:
• Planning of pregnancies so that they occur at
the right time
• Spacing of births for optimal health of all family
members,
• Stopping of births when the total size has been
attained.
Male Involvement
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What is the commonest method
used by UON students?????
•
•
•
•
•
•
•
•
•
P2, Postinor 2, Emergency pill, the Friday pill
Pills
Coil
Patch
Condoms
Injection
Spermicide
Calender/Counting days
Natural 44
You can have a healthy sexual life
• Preventing pregnancy
• Preventing infection
• Having a healthy baby
Let's discuss
the choices
or
The Pill
• Take a pill every day
• Women with HIV or on ART can use safely
and effectively
• Does not protect against STI or HIV transmission
Use condoms to prevent infection
• Less menstrual bleeding and cramps
• Most common side-effects:
headaches, nausea, spotting
Who can and cannot use the Pill
Most women with HIV or on
ART can use this method
safely and effectively
But usually cannot use the Pill if:
Smokes
cigarettes
AND
age 35
or older
High blood
pressure
Taking
rifampicin
Gave birth
in the last 3
weeks
Breastfeeding
6 months
or less
May be
pregnant
Some other
serious health
conditions
Benefits of Contraception
• To the women:
– Helps women avoid pregnancies at the extremes of maternal
age.
– Helps women decrease risk of death by decreasing parity
– Helps women prevent high risk pregnancies
– Helps women eliminate/decrease abortion risks
– Improve health of women thru noncontraceptive benefits of
FP eg. Prevention of STIs, & reproductive tract cancers(Ca
ovary & endometrium)
Hormones:Mechanisms of
Action/menstrual cycle
• Suppression of
hormones responsible
for ovulation
• Thickening of cervical
mucus, blocking
sperm
Hormonal Methods
•
•
•
•
•
•
•
Combined pill (micro-pill)
Progestin-only pill (mini-pill)
Contraceptive patch
Vaginal ring
Contraceptive injections
Contraceptive implants
Emergency pill
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Non-hormonal Methods
•
•
•
•
•
Condoms- male and female user
Diaphragm
Cervical cap
Intra uterine device
Surgical or permanent methods
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Women and education
2000
Secondary School
896,000
Marmara University Istanbul
1975
Secondary School
167,000
2008 TNSA
2000
University
Graduate
910,000
1975
University
Graduate
56,000
Improvement of women’s welfare
Life satisfaction data collected from 450,000 women
• Biggest contributor to an increase in ‘life satisfaction’ was access to contraception
because it increases:
Investment in education
Probability of working
Level of income
Contraceptive effectiveness
Method
Reliability
No. of women out of 1000 who get
pregnant per year with perfect use
Male condom1-6
Reasonable
70
Female condom7
Reasonable
50
Combined pill1-69 ( eg. Yasmin)
Very high
0.3
Progestin-only pill1-6
Very high
4
Patch1-6
Very high
10
Vaginal ring1-6
Very high
10
Injection1-6
Very high
0.3
Implant7
Very high
0.09
High
5
Very high
0.1
Reasonable
60
Male sterilisation7
Very high
0.1
Female sterilisation1-6
Very high
0.5
Withdrawal method1-6
Unreliable
100
Low- reasonable
30-90
IUD7
IUS1-6 ( eg. Mirena)
Diaphragm1-6
Natural method7
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Comparing effectiveness of methods
More effective
Less than 1 pregnancy per
100 women in one year
How to make your method
most effective
After procedure, little or nothing to
do or remember
Implants
Female
Sterilization
Vasectomy
IUD
Vasectomy: Use another method for
first 3 months
Injections: Get repeat injections on
time
LAM (for 6 months): Breastfeed
often, day and night
Injectables
LAM
Pills
Pills: Take a pill each day
Condoms, diaphragm: Use correctly
every time you have sex
Male
Condoms
Female
Condoms
Diaphragm
Fertility-Awareness
Based Methods
Fertility-awareness based methods:
Abstain or use condoms when fertile.
Newest methods (Standard Days Method
and TwoDay Method) may be easier to use.
Withdrawal, spermicide: Use
correctly every time you have sex
Less effective
About 30 pregnancies per 100
women in one year
Effectiveness chart
Withdrawal
Spermicide
Choosing the best contraception for
you and your partner:
• Important to avoid pregnancy? Could you manage if
you became pregnant.
• Age/health as factors, as there are medical conditions
& circumstances for which you should avoid pg and for
which the use of certain methods of contraception is
no allowed/advisable.
• Your relationship status-committed/open?. How often
do you have intercourse? Complete family/still want to
have children?
• Contraceptive method that is independent of your
sexual activity or could you integrate a
barrier/behavioural method within your sexual activity?
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Sex
• Worldwide acts of heterosexual intercourse
take place each day resulting in:
– Fun
– 910,000 conceptions and
– 365,000 sexually transmissible infections.
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The 910,000 daily conceptions
result in:
• Only 390,000 live births.
• Reproductive Wastage:
– 130,000 spontaneous abortions
– 90,000 induced abortions
– 10,000 stillbirths.
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EVERY EIGHT MINUTES
• “A woman dies somewhere in a “developing”
country due to complications from an unsafe
abortion.
• She was likely to have had little or no money to
procure safe services, was young… living in
rural areas and with little social support ….
• She probably first attempted to self-induce the
termination and after that failed, she turned to
an unskilled, but relatively inexpensive,
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provider.”
EVERY MINUTE






114 Million acts of sexual intercourse take
place
380 Pregnancies occur
190 Unplanned or unwanted pregnancies
occur
110 pregnancy related complications occur
40 unsafe abortion take place
Woman
1 death occurs
Centre of statistics
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Globally
Each year, 46 million induced
abortions take place
globally
• An estimated 20 million are
unsafely conducted
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WHERE DO WOMEN DIE TODAY?
African proverb
“ Every pregnant woman has one foot in
the grave”
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Case study
A
ten year old girl was raped in December 2011.
She duly was taken to a Provincial General Hospital
examined, treated, not given ECP.
2 months later she went back to the same hospital
with complaints that were confirmed to be a
manifestation of early pregnancy.

She
was told “Pole” but we cannot help you. Just
carry the pregnancy. A month later she reported to
the same hospital with unsafe abortion.
Take
a moment to ponder over how we as a society
have handled this young lady
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Abortion:
The Link between
legality and safety
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Genesis of Abortion
1. SEX (wanted or unwanted), leading to
2. UNWANTED PREGNANCY (unintended,
unplanned, mistimed), leading to
3. ABORTION (safe or unsafe)
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Definition of unsafe abortion
• WHO defines unsafe abortion as “a procedure
for terminating an unwanted pregnancy
either by persons lacking the necessary
skills or in an environment lacking the
minimal medical standards or both.”
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Contribution of Unsafe abortion to
maternal mortality
Haemorrhage
24.8%
Sepsis
14.9%
Indirect
causes
19.8%
Other direct
causes
7.9%
Hypertensive
disorders
Unsafe
abortion
Obstructed labour
6.9%
12.9%
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7/17/2015 Fact Sheet on Maternal Mortality, 1998.
Source: Safe Motherhood
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12.9%
Unsafely Induced Abortion
• Unsafely induced abortion constitutes about
70% of cases of abortion seen in health
facilities
• Presents with pain, haemorrhage, infection,
presence of foreign bodies, and injuries to
organs such as uterus, intestines, bladder,
rectum etc
• Due to restrictive law and stigma the procedure
is clandestine, hence delay in seeking
7professional care for complications
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Complications of unsafe
abortion
– Heavy bleeding
– Damage/injury to the uterus, intestines and other
organs
– Infection (post-abortion sepsis)
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Magnitude of abortion problem
• 308,197 abortions occur in Kenya annually with 20,341
(7%) being hospitalized
• This translates to 844 abortions per day
• Most women cited wrong timing as the reason for
terminating the pregnancy
• National rate of abortions per 1,000 women aged 15-49
years is 44.7
• 7Current estimated abortion ratio is 28 per 100 live
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5births
Magnitude cont..
• About 1% of women admitted to public hospitals
annually with abortion-related complications die.
• Abortion and abortion related complications
account for almost half of all gynecological
admissions in Kenya
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Abortion debate can go on
and on……
…….. but the lives
ofrally
Pro-choice
our mothers, sisters
and daughters
cannot wait!!
Pro- life rally
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The Legal status of abortion helps determine
the availability of safe, affordable abortion
services in a country, which in turn
influences rates of Maternal morbidity and
mortality
……………Anika Rahman et al 1998-President and CEO of Ms Foundation
and lawyer by profession
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Why the need to focus on youth
• Youth have energy, innovativeness,
character and orientation define the pace
of development and security of a nation.
• Through your creative talents and labour
power, a nation makes giant strides in
economic development and socio-political
attainment.
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Why the need to focus on youth
• Your effective involvement is essential to
the achievement of Kenya’s vision 2030.
• Greater reproductive health risks than
adults-More susceptible to STI’s including
HIV/AIDS, unsafe abortion, peer pressure,
coercion, vulnerable to exploitation for
sexual favours
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Youth issues
• Access to education
• Early and risky sexual encounters
• Unwanted pregnancy, early marriage and early child
bearing
• Low contraceptive use and unmet need among the
youth
• HIV/AIDS and youth
• Youth friendly service provision
• Policy and programme implications and
recommendations
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Youth friendly services
•
•
•
•
•
•
Sexuality info
Contraceptive counseling
Pregnancy testing
Safe abortion services
Sexual abuse counseling
Relationship and sexuality counseling
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• Provision of comprehensive sexuality education is the
most effective way of giving young people the info and
life skills they need about their lives, including their
sexual and reproductive health
• Include youth in the decision-making process. In order
to be fully included in the decision–making process
and to give informed consent young people need
accurate and comprehensive info presented in an
accessible manner
• Recognizing that young people have valuable insights
into their health and well-being that adults do not have
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Service providers
•
•
•
•
Staff conversant with youth issues
Respect shown to young people
Privacy and confidentiality maintained
Adequate time given for client-provider
interaction
• Peer counselors available
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Common SRH
•Unprotected sexual activity
•HIV/AIDS : STIs
•Unwanted / Teenage
pregnancy: Unsafe abortion
• Sexual violence: FGM
•Relationships / adolescence
stage
Underlying factors
•Lack of employment
•Poor communication
between parents and young
people
•Ignorance of SRH concerns
•Media and Peer influence
•Drug and substance abuse
Youth Friendly SRH
services
Availability, perceptions
and views of SRH
services
Policy
Feasibility
in the
context of
Factors shaping access current
and utilisation of SRH policy
environmen
services
t and
Models of YF SRH
service
service provision provision
(youth-only and integrated
settings
services at community,
Outcome
Improve
Sexual
and RH
for
young
people
facility levels)
•Strengths
• Weakness
Views and experiences from Young People (aged 12-24), Health
Service Providers, Health Facility In-charges /Managers and
Community Members
YP and available SRH services
Integrated services
• Young girls coming for ANC
services, reported the services
to be “good and helpful”
• They are assisted well and
given proper advice when they
visit the ANC clinics
• Health care providers were
good unlike the support staff
• Improved staff attitude
especially in Govt managed
facilities
• Some of the facilities were
within walking distance
• Cost – affordable or even free
• General facility / service
improvement has been noted
over the previous three years
Youth-only services
• Appreciative of the services
• Prevents idleness
• Involved in activities that help
enhance their self-esteem,
improve communication skills,
interpersonal interaction
• A stepping stone to further
careers
• Receive skills training,
computer, use of internet
• Can make college/university
applications
• Confidence builder,
• Information gap-bridge
including body hygiene /care
• A place of encouragement
• Encourages stepwise use of
services
• Taught on HIV/STI prevention
Policy and programme implications
and recommendations
• Implement laws with regards to ending
child marriage- Childrens’ act sets
minimum age for marriage at 18 years and
specifies that all persons below that age
have the right to health and medical care.
• Sexual Offences Act-enforces stringent
measures to protect adolescents from
abusive behaviour-Kenya constitution
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Strategies
• Multi-sectoral approach –MOH, Education,
Gender, Communication, Planning finance
NGO’s and media
• Youth friendly health services
• Comprehensive and harmonized sexuality
education
• Youth involvement and participation
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Vulnerable Youth inclusion
1.
•
•
•
•
National ASRH policies where relevantrefugees, street children
married adolescents,Victims of violence
orphans, drug users
adolescent sex workers
2. Health care workers cannot meet all the
needs of adolescents alone and should join or
create networks that act together and
maximise resources
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Public-Private Partnerships
• Strengthening health systems- Greater
accessibility by adolescents to SRH services
and supplies
• Private sector involvement-Social franchising
schemes, voucher systems, and social
marketing –improve access to services and
supplies
• Establish mechanisms for scaling up of
successful interventions with government
support and keep expansion in mind when
designing new programmes
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Strategies for healthy youth
development
• Support the development of youth leadership
• Programmes should involve parents,
community leaders and youth actively.
• Campaign for comprehensive, life skills-based
SRH education in schools and communities.
• Design multi-sectoral, integrated
programmes that address multiple youth
needs.
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Legislation targeting youth
• Female genital mutilation/cutting-Alternative
forms of rites of passage.
• Explicitly address gender and other inequities
• Ensure very young adolescents (10–14 years)
are also targeted in ASRH programmes.
• Advocate for keeping young people in school as
long as possible.
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Legislation targeting youth…….
• Laws that protect adolescents from sexual
exploitation.
• Government to enforce laws on age of
marriage.
• Where abortion is legal, promote greater
accessibility for adolescents combined with
post-abortion counselling and access to
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contraception.
Lessons Learned
• Whenever possible, programming and interventions should
build upon existing sustainable structures
• Partnership at national and community levels enhance,
ownership, acceptance and sustainability. Involvement of
relevant stakeholders (youth and community), especially
program beneficiaries evaluation;
• Need to focus on VYA (10-14yr olds) before they are sexually
active
• Need to reach rural and non-literate population with information
and services
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“We need you and your ideas because
the difference between our world today
and our world tomorrow rests with you.
You are the future and more-so you are
the present”
Thoraya Ahmed Obaid,
UNFPA Executive Director.April 2004
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