PUB 460 Lecture 2 - Burden of reproductive ill health.pdf

BURDEN OF REPRODUCTIVE ILL HEALTH PUB 460 Dr. Gauri Desai Reproductive Health • Good reproductive health: State of complete physical, mental and social well-being in all matters relating to the reproductive system. • Implies that people are able to have a satisfying and safe sex life, the capabil...

BURDEN OF REPRODUCTIVE ILL HEALTH PUB 460 Dr. Gauri Desai Reproductive Health • Good reproductive health: State of complete physical, mental and social well-being in all matters relating to the reproductive system. • Implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so. https://www.unfpa.org/sexual-reproductive-health#readmore-expand Reproductive Health • To have a good reproductive health, individuals – • Need access to accurate information and the safe, effective, affordable and acceptable contraception method of their choice • Must be informed and empowered to protect themselves from sexually transmitted infections. • When decide to have children, individuals must have access to services that can help them have a fit pregnancy, safe delivery and healthy baby. Reproductive Ill Health • Refers to morbid conditions such as infections and injury and to nonmorbid measures of reproductive health that directly contribute to adverse reproductive health outcomes, including unwanted pregnancies and violence against women. https://apps.who.int/disasters/repo/13849_files/i/reproductive_health_ppt.pdf Reproductive Ill Health https://apps.who.int/disasters/repo/13849_files/i/reproductive_health_ppt.pdf Reproductive Ill Health • 4 components (in this lecture) 1. Unintended pregnancies, 2. Unsafe abortions, 3. Infertility, 4. Female genital mutilation (FGM). Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 1: Only promiscuous women and reckless teenagers have unintended pregnancies • Fact: Any fertile woman, regardless of age, marital status or background, can get pregnant unexpectedly, as can people who do not identify as women • Men play a key role: worldwide, almost one-quarter of women are unable to refuse sex • Rape causes unintended pregnancy at rates equal to, or greater than, consensual sex https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 2: Women don’t use contraceptives because they don’t know about or can’t get them • Fact: Lack of awareness about, or access to, contraception is now one of the least commonly cited reasons for non-use • Biggest reasons are concerns about side effects, having infrequent or no sex, and opposition to condoms and other methods • Misinformation about long-term effects on fertility adds to fears about contraception https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 3: Legal, available access to abortion encourages women to have unprotected sex • Fact: Rates of unintended pregnancy tend to be lower in countries with more liberal abortion laws, where access to safe abortion is available on request or in most circumstances • In countries where abortion is restricted or banned, more women get pregnant unexpectedly • Reasons? https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 4: Unintended pregnancy is always entirely a person’s fault • Fact: Social and cultural factors are at play • When societies restrict women’s reproductive agency, motherhood can become the default rather than a considered decision and desire. https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 5: Married women don’t have to worry about unintended pregnancies • Fact: Married women are just as susceptible to unintended pregnancy as other women, in some cases more so; marriage ≠ wanting to have children at any point https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 6: Unintended pregnancies are unwanted pregnancies • Fact: Despite more than 60% of unintended pregnancies ending in abortion, not all are unwanted • Many might have the desire to have children, but likely haven’t thought of the timing of having them https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies – myths vs. facts • Myth 7: Unintended pregnancy is not a real crisis • Fact: The inability to exercise control over their reproductive health traps millions in a cycle of hardship and missed opportunity that ripples through generations • Empowering women to make conscious and deliberate choices about their pregnancies is essential for advancements in education, health and gender equality https://turkiye.unfpa.org/en/news/7-myths-about-unintended-pregnancy Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies are common https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide Reproductive Ill Health – Unintended pregnancies • Unintended pregnancies are common https://www.who.int/news/item/23-07-2020-new-estimates-show-worldwide-fall-in-unintended-pregnancies-since-1990-1994 Reproductive Ill Health – Unintended pregnancies • Why is it important to focus on unintended pregnancies? Individual level: • Unintended births and induced abortions • Unintended births often occur among young women who are emotionally and physiologically not mature • Effects on the health of the mother, the pregnancy, and its outcome • Shortened interpregnancy intervals; hampered perinatal outcomes • Induced abortions in places where it is illegal – women resort to services provided by untrained individuals in unsafe environments • Direct threat to health, even deaths Reproductive Ill Health – Unintended pregnancies • Why is it important to focus on unintended pregnancies? Population level: • Population growth • # preventable deaths from unsafe abortions in places where it is illegal • Ability of women (often younger women) to complete education and gain employment – less data on this • Ability of women to contribute to economy • Gender equality • YouTube video [2:42]: https://www.youtube.com/watch?v=l6P9FSxWiHY&t=156s&ab _channel=UNFPAT%C3%BCrkiye Measuring Unintended Pregnancies • Complicated because many are terminated; terminations are underreported • Demographic and Health Surveys (DHS) are the main source of data on unintended births. • 4 approaches: 1. Answers to questions on total desired family size 2. Prospective questions on whether another child is wanted 3. Retrospective questions on each recent birth to ascertain whether the child was wanted, unwanted, or mistimed by two or more years 4. London Measure of Unplanned Pregnancy Measuring Unintended Pregnancies 1. Answers to questions on total desired family size • • • Births that exceed total desired family size are defined as unwanted If they are equal to or less than total desired family size, they are considered wanted Mistimed births are not counted • What’s the issue with this approach? • Desired total family sizes are, in part, a rationalization of actual family sizes Unwanted births are likely to be underestimated • Measuring Unintended Pregnancies 2. Prospective questions on whether another child is wanted • • Used in prospective studies wherein individuals are asked if they want a child before they are pregnant Mistimed births are not counted • What’s the issue with this approach? • Limited utility - few prospective studies are conducted Measuring Unintended Pregnancies 3. Retrospective questions • • Questions on each recent birth to ascertain whether the child was wanted, unwanted, or mistimed by two or more years Incorporates mistimed as well as unwanted births • What’s the issue with this approach? • • Reluctance of mothers to report children as unwanted or mistimed Estimates not always accurate Measuring Unintended Pregnancies 4. London Measure of Unplanned Pregnancy • Psychometrically validated measure of the degree of intention/planning of a current or recent pregnancy • A measure of both pregnancy planning and intention, makes no distinction between these broad concepts • Sum of scores calculated; 0–3 unplanned; 4–9 ambivalent; 10–12, planned • Issue: Not widely used yet Hall et al (2017): London Measure of Unplanned Pregnancy: guidance for its use as an outcome measure Measuring Unintended Pregnancies • The four approaches to measurement yield very different results • No consensus exists on how best to obtain valid estimates of unintended births Unsafe Abortions Note on safe abortions • A first-trimester abortion is one of the safest medical procedures and carries minimal risk: Major complications (those requiring hospital care, surgery or transfusion) occur at a rate of less than 0.5%. • Studies show there are no long-term consequences of abortion on women’s: • Physical health (including breast or other cancers) • Mental health Source: Guttmacher Institute. https://www.guttmacher.org/fact-sheet/induced-abortion-united-states Barriers to safe abortion • • • • • • Restrictive laws Poor availability of services High cost Stigma The conscientious objection of health-care providers and Unnecessary requirements, such as mandatory waiting periods, mandatory counselling, provision of misleading information, third-party authorization, and medically unnecessary tests that delay care. • Restricting access to abortion does not reduce the number of abortions https://www.who.int/health-topics/abortion#tab=tab_3 Reproductive Ill Health – Unsafe abortions • An unsafe abortion is a life-threatening procedure. • It includes selfinduced abortions, abortions in unhygienic conditions, and abortions performed by a medical practitioner who does not provide appropriate postabortion attention. Reproductive Ill Health – Unsafe abortions • Unintended pregnancy rates are highest in countries that restrict abortion access and lowest in countries where abortion is broadly legal. • As a result, abortion rates are similar in countries where abortion is restricted and those where the procedure is broadly legal (i.e., where it is available on request or on socioeconomic grounds). Reproductive Ill Health – Unsafe abortions • Why is it important to focus on unsafe abortions? 1. Physical complications of unsafe abortion – • Hemorrhage (heavy bleeding), infection, sepsis, and trauma to the cervix, vagina, uterus, and abdominal organs. • One in four women who undergo an unsafe abortion is likely to develop temporary or lifelong disability requiring medical care. 2. Maternal mortality – Between 4.7% and 13.2% of all maternal deaths can be attributed to unsafe abortion; disproportionately affects LMICs https://www.who.int/news-room/fact-sheets/detail/abortion Reproductive Ill Health – Unsafe abortions • Why is it important to focus on unsafe abortions? 3. Financial burden for women, communities and health systems – • US$ 200 million in out-of-pocket expenses of individuals and households, for the treatment of post-abortion complications, in subSaharan Africa alone. • US$ 922 million in loss of income as a result of long-term disability, due to infertility or pelvic inflammatory disease caused by unsafe abortion. • YouTube video [4:00]: https://www.youtube.com/watch?v=adFe3XsLvnQ https://www.who.int/news-room/fact-sheets/detail/abortion Measuring Unsafe abortions • In countries in which abortion is legally restricted or socially stigmatized, official statistics on abortion are usually nonexistent, or unreliable 1. Direct approach: In-depth interviews • Issue: Unreliable 2. WHO’s indirect approach: Use of information on unsafe abortion and associated mortality from hospital records and surveys of abortion providers, women’s abortion-seeking behavior, postabortion care • These data are used to predict regional-, country-, and globallevel estimates using appropriate statistical methods • Issue: Underestimation likely occurs https://www.who.int/news-room/fact-sheets/detail/abortion Infertility Reproductive Ill Health – Infertility • WHO: Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. • Infertility can be primary or secondary. • Primary infertility is when a pregnancy has never been achieved by a person, and secondary infertility is when at least one prior pregnancy has been achieved https://www.who.int/news-room/fact-sheets/detail/infertility Reproductive Ill Health – Infertility Global prevalence of primary infertility, 2010 https://www.mhtf.org/2017/01/18/the-burden-of-infertility-global-prevalence-and-womens-voices-from-around-the-world/ Reproductive Ill Health – Infertility Global prevalence of secondary infertility, 2010 https://www.mhtf.org/2017/01/18/the-burden-of-infertility-global-prevalence-and-womens-voices-from-around-the-world/ Reproductive Ill Health – Infertility https://library.med.utah.edu/ kw/human_reprod/seminars/ seminar2A.html Reproductive Ill Health – Infertility • Why is it important to focus on infertility? 1. Right of individuals and couples to found a family • Every human being has a right to the enjoyment of the highest attainable standard of physical and mental health. • Individuals and couples have the right to decide the number, timing and spacing of their children. 2. Addressing infertility can also mitigate gender inequality • Both women and men can experience infertility, yet women in a relationship with a man are often perceived to suffer from infertility, regardless of whether they are infertile or not 3. Social impact – • Negative social impacts on the lives of infertile couples and particularly women, who frequently experience violence, divorce, social stigma, emotional stress, depression, anxiety and low self-esteem https://www.who.int/news-room/fact-sheets/detail/infertility Female Genital Mutilation Reproductive Ill Health – Female Genital Mutilation • Refers to “all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for nonmedical reasons” • Violation of girls’ and women’s human rights • At least 200 million girls and women have been cut in 30 countries with representative data on prevalence • Exact number remains unknown https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation Reproductive Ill Health – Female Genital Mutilation • Mostly carried out by traditional practitioners. • Recently, greater involvement of health care providers in performing FGM due to the belief that the procedure is safer when medicalized. • WHO strongly urges health care providers not to perform FGM. Image: Time Magazine https://www.who.int/news-room/fact-sheets/detail/female-genitalmutilation Reproductive Ill Health – Female Genital Mutilation • FGM is recognized internationally as a violation of the human rights of girls and women. • It is nearly always carried out on minors and is a violation of the rights of children. • The practice also violates a person's rights to health, security and physical integrity; the right to be free from torture and cruel, inhuman or degrading treatment; and the right to life, in instances when the procedure results in death. https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation Reproductive Ill Health – Female Genital Mutilation • Why is FGM performed? Several reasons – 1. Psychosexual reasons: Way to control women’s sexuality, which is sometimes said to be insatiable if parts of the genitalia are not removed. Thought to ensure premarital virginity and fidelity afterward, and to increase male sexual pleasure. 2. Sociological and cultural reasons: Seen as part of a girl’s initiation into womanhood and as an intrinsic part of a community’s cultural heritage. 3. Hygiene and aesthetic reasons: In some communities, the external female genitalia are considered dirty and ugly and are removed, ostensibly to promote hygiene and aesthetic appeal. 4. Socio-economic factors: In many communities, FGM is a prerequisite for marriage. Where women are largely dependent on men, economic necessity can be a major driver of the procedure. FGM sometimes is a prerequisite for the right to inherit. It may also be a major income source for practitioners. https://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questions#practice_origins Reproductive Ill Health – Female Genital Mutilation Who is affected? • An estimated 200 million girls and women alive today are believed to have been subjected to FGM • Girls and women who have undergone FGM live predominately in sub-Saharan Africa and the Arab States • FGM is also practiced in select countries in Asia, Eastern Europe and Latin America • It is also practiced among migrant populations throughout Europe, North America, Australia and New Zealand • This number of girls cut each year is projected to rise to 4.6 million girls in the year 2030. https://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questions#women_affected Reproductive Ill Health – Female Genital Mutilation UNICEF, 2016 data https://en.wikipedia.org/wiki/Prevalence_of_female_genital_mutilation Reproductive Ill Health – Female Genital Mutilation UNICEF, 2014 data  UNICEF video [3:12]:  https://www.youtube.c om/watch?v=Pjy8jRRG HcU&feature=emb_logo https://blogs.unicef.org/blog/five-things-you-didnt-know-about-female-genital-mutilationcutting-2/ Reproductive Ill Health – Female Genital Mutilation • Consequences of FGM Immediate consequences: • • • • • • • • • • severe pain excessive bleeding (hemorrhage) genital tissue swelling fever infections e.g., tetanus urinary problems wound healing problems injury to surrounding genital tissue shock death https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation Reproductive Ill Health – Female Genital Mutilation • Consequences of FGM Long-term consequences: • urinary problems (painful urination, urinary tract infections) • vaginal problems (discharge, itching, bacterial vaginosis etc.) • menstrual problems (difficulty in passing menstrual blood etc.) • sexual problems (pain during intercourse etc.) • increased risk of childbirth complications and newborn deaths • need for later surgeries • psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.) https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation Question Bank 1. Why is it important to focus on unintended pregnancies? Name 2 individual level reasons and 2 population level reasons. 2. Why is it important to focus on infertility? 3. Name 2 short term and 3 long term implications of female genital mutilation.