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Interventions
Maternal and Reproductive Health
There is strong international consensus regarding interventions that directly or indirectly improve maternal and reproductive health.1-5
Reproductive Health Interventions1, 2
Health Interventions
* Universal access to contraception
* STI and HIV prevention and treatment
* Safe pregnancy and delivery
* Comprehensive sexuality education promoting
gender equality and human rights.
Improving Status of Women and Girls
* Marriage after age 18
* Girls’ education through secondary school
* Prevention of sexual coercion and violence
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- Family planning services: the health benefits of spacing and limiting births for mothers and children are well known. Filling the unmet need for family planning also has economic benefits.
- STI/HIV/AIDS prevention, screening, treatment and care: condom use, STI testing and treatment, and adolescent education and counseling can prevent death, disability and infertility. Integrating reproductive health and HIV/AIDS services is cost-effective, reduces stigma and increases access to services for the poor.
- Maternal health: prenatal care, emergency obstetrical care, nutritional supplements, including vitamin A and zinc, presence of a skilled birth attendant, antibiotics and observation of the mother and newborn are life-saving interventions.
- Improving the status of girls and women: girls schooled beyond primary grades marry and have children later, have fewer and healthier children and have higher income potential. Gender-based violence prevention programs that involve men and boys and programs challenging inequitable social norms can improve women’s and children’s physical and emotional health and well being.
Emergency Contraception
Emergency contraceptives prevent unintended pregnancies within the first few days after unprotected intercourse. This method is useful in cases when a condom breaks, diaphragm or cervical cap slips out of place, and among victims of sexual assault. Emergency contraceptive pills (ECPs) work by preventing ovulation, but they are ineffective once the process of implantation has already started. ECPs can be bought using a prescription only, and are not appropriate for regular use. Women who are already pregnant should not use emergency contraception, although limited studies show that the pills do not harm a pregnant woman or her fetus. ECPs should be taken as soon as possible within the first five days of intercourse, and are 60-90 percent effective.6
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Family Planning
More than half of all women between the ages of 15-49 in the developing world (705 million) are at risk of unintended pregnancy.7 At least 200 million do not have access to effective modern contraceptives – this includes women who use traditional methods of contraception, which can have high failure rates if used improperly. Satisfying this unmet need could prevent 52 million unintended pregnancies and save more than a million lives per year.7 Thirty-three percent of couples count on sterilization to prevent unwanted pregnancies, and 38 percent depend on reversible methods of contraception.7
Synergistic effects of family planning interventions include protection from sexually transmitted diseases (STIs) and HIV/AIDS and improved linkages to existing systems of health-care. Women who visit clinics for contraception services are also more likely to be screened, diagnosed and treated for cervical cancer.7
Other benefits of contraception include improvements in women’s empowerment, employment opportunities, partner relationships and quality of life.8
Satisfying the Unmet Need For Contraception
Costs and Benefits of Contraception Use
Modern contraception methods cost about $7.1 billion annually and prevent:7
- 215,000 pregnancy-related deaths
- 127 million unintended pregnancies
- 60 million unplanned births
- 2.7 million infant deaths
- 685,000 children losing their mothers as a result of pregnancy-related deaths
- 105 million induced abortions
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Birth spacing. To reduce the risk of adverse maternal, perinatal, and infant outcomes, women should wait at least two years between pregnancies.9 Recent studies supported by the United States Agency for International Development (USAID) found that a longer birth spacing of 3 to 5 years may be more beneficial.
Contraception methods. A successful family planning program should provide individuals with a range of contraceptive methods and provide the information that clients need to select the best contraceptive method for their individual circumstances.10
Appropriate decision making tools, such as illustrated flip charts and medical eligibility criteria wheels, are tools that can guide decisions about family planning options by providing information about the relative effectiveness, correct use, side effects, and the health risks and benefits of different contraceptive methods.
Young women often have a particularly difficult time accessing contraception. Because of their age, girls and adolescents who seek contraceptive methods are often stigmatized in their communities. Cultural norms, such as the expectation that women should remain chaste until marriage, also prohibit young women from accessing family planning services, and lead to inequitable relationships with men.
| Method |
Description |
Failure Rate
(Number of Pregnancies Expected per 100
Women per Year) |
| Spermicide |
A foam, cream, jelly, film, suppository or tablet that contains nonoxynol-9, a sperm killing agent |
20-50 |
| Cap |
A soft rubber cap with a round rim that fits around the cervix |
17 (Prentiff Cap)
23 (Fem Cap)
|
| Sponge |
A small, circular foam sponge that contains a spermicide |
14-28
(May be less effective for women who have had a child or those with yeast infections)
|
| Diaphragm |
A dome-shaped rubber disk with a flexible rim that covers the cervix so that sperm cannot reach the uterus |
17 |
| Male condom |
A protective sheath placed over the erect penis to block the passage of sperm |
11 |
| Female condom |
A lubricated polyurethane sheath, with a closed end that is inserted into the vagina |
21 |
Oral Contraceptives
– Combined pill |
A pill that suppresses ovulation by the combined actions of progestin and estrogen |
1-2 |
Oral Contraceptives
– Progestin-only mini pill |
A pill containing progestin that thickens and reduces the cervical mucus to prevent the sperm from reaching the egg |
2 |
| Combined hormonal patch |
A skin patch worn on the upper body, lower abdomen, or buttocks that releases estrogen and progestin into the blood stream |
1-2 |
| Combined hormonal ring |
A flexible ring about 2 inches in diameter that is inserted into the vagina and releases estrogen and progestin |
1-2 |
| Injection (Depo-Provera) |
An injectable progestin that inhibits ovulation, prevents sperm from reaching the egg, and prevents the fertilized egg from implanting in the uterus. |
Less than 1 |
| Injection (Lunelle) |
An injectable form of estrogen and progestin |
Less than 1 |
| Intrauterine device |
A small, flexible T-shaped device inserted into the uterus by a health care professional |
Less than 1 |
| Implants |
One or several small rods placed under the skin of a woman’s upper arm, where they steadily release the contraceptive steroid levonorgestrel |
Less than 1 |
| Female sterilization |
There are two different types of female sterilization – tubal ligation and Essure.
- Tubal ligation is a surgical technique that blocks a woman’s fallopian tubes, thereby preventing the egg from traveling to the uterus.
- Essure is a small, metallic, spring-like coil that is inserted into the fallopian tubes, causing scar tissue to form, thus blocking the fallopian tubes.
|
None (Tubal ligation)
Less than 1 (Essure)
|
| Male sterilization |
Tying, sealing, or cutting a man’s vas deferens so that the sperm cannot travel from the testicles to the penis |
Less than 1 |
Prenatal, Perinatal and Postnatal Care of Mother and Infant
Pregnancy and childbirth are particularly vulnerable periods. Each year, more than half a million women, nearly all from developing countries, die from complications during pregnancy or childbirth; about 10 million women endure life-threatening complications, sometimes leading to long term disability.12, 13 Unfortunately, financial constraints, long distances, poor communication and transport systems, weak referrals, and cultural norms often prohibit women from accessing the care that they need for a safe pregnancy. A severe shortage of health-care workers also hampers efforts to provide care for safe childbirth.
Prenatal care. For prenatal care to be effective, pregnant women need at least four prenatal visits at specific times during their pregnancies.14 Most prenatal care is provided by a midwife or nurse, or appropriately trained lower-level health-care workers, including auxiliary nurse/midwives and community health workers.15 Screening for and treatment of disorders and provision of preventative interventions are two of the main components of the prenatal-care package.14
- Prenatal care educates pregnant mothers about danger signs, potential complications and where to seek treatment during pregnancy, and provides counseling about hygiene, diet, and the care and feeding of babies.
- Prenatal care also provides health-care workers with an opportunity to diagnose and treat pregnant mothers for existing conditions, such as HIV/AIDS, STIs, malaria and TB.
- Correct diagnosis and appropriate drug therapy can prevent mother-to-child transmission of disease, limit sexual partners’ exposure, and reduce the risk of co-infection.
- The development of a birth plan is another important part of prenatal care. The birth plan should include, if possible, the decision to give birth in a health care facility, or, if not, arrangement for the assistance of a skilled birth attendant in the home. If a pregnant woman decides to give birth at home, she should procure a delivery disposable kit with basic instructions on good birthing practices.16
Prenatal Care by Region15
* CEE/CIS – Central and Eastern Europe/Commonwealth of Independent States and Baltic States
* East Asia/Pacific – Excluding China
- Women in urban areas are more likely to receive prenatal care than those in rural areas. Overall, 86 percent of urban women report at least one prenatal visit, versus 65 percent of rural women. Educated women and wealthy women are also more likely to receive prenatal care.15
- Women who receive prenatal services are more likely to give birth assisted by a trained health care provider than women who did not receive prenatal care; women reporting at least four prenatal visits are 3.3 times more likely to deliver in a medical facility than other women.15
Perinatal care. An estimated 10 million women suffer life-threatening complications at birth each year, and about 5-15 percent of all births will need emergency obstetric care.18
Roughly 60 percent of women in the developing world receive assistance during delivery from a skilled health-care worker, though coverage has increased in nearly all regions since 1990. The greatest progress has been made in the regions of Middle East and North Africa, and South Asia.18
- In some countries, great disparities in access to skilled birth attendants exist between the wealthiest and poorest women. For example, in Haiti, while 68 percent of women in the wealthiest quintile give birth in the presence of skilled attendants, only 6 percent of women in the poorest quintile do.18
- Many potentially fatal complications can be treated with emergency obstetric care. The unmet need for emergency obstetric care results in millions of cases of death or disability.
- Emergency obstetric care refers to a set of medical interventions that can be provided by a nurse, midwife or doctor in a clinic or other medical facility.17
- These services include the administration of antibiotics and anticonvulsants, assisted vaginal delivery with forceps or vacuum extractor, manual removal of the placenta and removal of retained products following abortion or miscarriage.
- Emergency obstetric care is also necessary to stop bleeding, provide blood transfusions, or provide emergency transportation to a hospital in the event of postnatal hemorrhage, which is the leading cause of maternal death.
Percentage of Women who Receive Emergency Obstetric Care in Rural Areas18
In Sub-Saharan Africa, one in 22 women will face the risk of dying from a pregnancy-related complication in her lifetime. However, in developed countries, women face a one in 7,300 risk of dying from a pregnancy-related complication or childbirth.18
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Postnatal Care. More than two-thirds of maternal deaths occur within a week of giving birth,19 with nearly half occuring within the first 24 hours.5 Hemorrhage, infections and eclampsia are the most common postnatal causes of maternal death and disability, followed by urinary tract problems and psychological problems.20 It is extremely important that new mothers receive support from trained caregivers for their physical and mental health needs during this period.
- WHO recommends that community health workers visit women who give birth without a birth attendant within the first 24 hours of delivery. WHO also suggests a second visit within three days of the delivery.10
Primary Elements of Postpartum Care20
|
6-12 hours |
3-6 days |
6 weeks |
6 months |
 |
Immunization
Warmth
Breathing
Feeding
Cord
|
Routine tests
Infection
Feeding
|
Immunization
Weight/Feeding
|
Weaning
Development
|
 |
Advice
Warning signs
Blood pressure
Blood loss
Pain |
Mood
Lochia*
Infection
Breast care
|
Anemia
Contraception
Recovery
|
General health
Contraception
Continuing Morbidity
|
*Lochia is post-partum discharge from the vagina and uterus.
Elimination of Unsafe Abortions
An estimated 20 million unsafe abortions occur every year, resulting in the death of about 67,000 women – 97 percent of which occur in developing countries.21, 22
- Nearly a fourth of the world’s population live in countries where abortions are illegal, and the prevalence of unsafe abortions is highest in countries with the most prohibitive abortion laws.21 Making abortion legal, safe, accessible, and socially acceptable has been shown to improve women’s sexual and reproductive health.
- Abortion procedures performed with manual vacuum aspiration are faster, safer and more cost effective than sharp cutterage.21 The syringe used in manual vacuum aspiration can be sterilized and used repeatedly, and the cannulas can be discarded or sterilized after each use. Mid-level health care providers can be trained to use vacuum aspiration without the supervision of doctors.23
- Increased access to safe, effective contraception can decrease the need for unsafe abortions and help to regulate fertility. Contraceptive counseling is effective, as many studies have shown that abortion patients accept contraception at a high rate.21
- A scale-up of post-abortion care would prevent death and disability. Clinical training of doctors and midwives, provision of manual vacuum aspiration and other supplies, greater supervision of medical facilities, and improved record keeping, are all effective interventions.21
Empowering Women and Girls
One of the most cost-effective and efficient ways to improve women’s health is to provide women and girls with greater power over their own lives. Education, economic independence, and access to health services can empower women and promote gender equity. Health-care workers should educate women about their reproductive rights, including their right to family planning services and contraceptives. Education, including sexual education, has also been shown to delay marriage and childbearing.
Men as Partners in Maternal Health
Men – as partners, fathers, husbands, brothers, policy-makers, and community and religious leaders – have a critical role to play in safeguarding the maternal health of women.2 In most developing countries, men are the chief decision-makers in matters relating to their wives’ social and economic independence, children’s education, and families’ health care and related needs.
Involving men in reproductive and sexual health programs can raise awareness of potential health problems, including HIV/AIDS and sexually transmitted infections, and provide a role for them in solving those problems.24
In 1994, the International Conference on Population and Development ‘Program of Action’ facilitated discussions on reproductive health aimed at increasing male participation in family planning programs and increasing sensitivity to inequitable gender norms.25 Men who hold rigid views about gender and the role of men are more likely to commit violence against women; programs that promote behavior change among men and boys are needed in societies where gender inequities are pervasive.26
Programs that aim to improve reproductive and maternal health can incorporate men in several ways – as partners, clients, or agents of change.26 A WHO review of 58 evaluations of these programs found that the majority of programs reported changes in behavior or attitude, including increased contraceptive and condom use, increased use of health services, and decreased sexual, physical, and psychological violence. The most effective programs attempted to transform gender stereotypes and encourage gender equality in relationships between men and women.27
Ending Violence Against Women
Violence against women includes physiological, psychological and verbal abuse. Women who have been abused are more likely to suffer from psychological and reproductive health problems than others. Gender-based violence also burdens health care systems and reduces the productivity of the workforce.28
- Health-care workers need training to be able to: identify the signs of violence against women; provide appropriate care; and make referrals to counselors, lawyers and law enforcement officers. After violent abuse, women often experience shame or guilt. Access to counseling helps restore women’s sense of self-worth and self-esteem.
A series of sexual violence initiatives were introduced to the Mexican health sector in 1999. One of these initiatives was the development of a comprehensive health model, which linked health services, legal assistance, and community-based initiatives. As a result, more than 5,000 health-care workers received training to recognize the signs of sexual violence.28
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- Data about violence against women can help to convince people to think critically about this issue by presenting men and women with credible evidence, raising awareness of an issue largely neglected by the community.28 Data gathering efforts may also yield useful information to strengthen advocacy efforts, help lawmakers understand the problem, and help public health professionals develop more effective interventions.
A UNFPA study found that media coverage, court cases and research findings helped to create a widespread awareness of violence against women in Bangladesh28
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- Many interventions to reduce violence against women incorporate men. For example, awareness campaigns, sensitization training, and public spokespersons targeting men may help to end male violence against women.28 More research is needed on male attitudes toward violence against women in order to implement more effective interventions.29
- Improving women’s legal status, including the enforcement of anti-violence laws and sensitization of the criminal justice system, is a key intervention in reducing sexual violence. Women need to know their rights, as this would encourage victims of domestic violence to seek legal protection from their abuser, without fear of losing their children or property. In countries where laws do not protect women against violence, governments need to make eliminating violence against women a legislative priority.29
- Education has a protective effect against sexual violence, as women and girls who have a higher education are less likely to be victims of sexual violence.29 Primary and secondary schools must be safe environments for women and girls. This may require changes in school policy, including the eradication of beatings as an acceptable form of discipline.
- It is important to implement culturally sensitive programs to address harmful cultural practices. For example, offering acceptable alternative practices to celebrate rights of passage may help to eliminate female genital mutilation (FGM).30 Men and boys should be involved in gender equity and women’s empowerment programs, and education programs to learn about the health risks of harmful cultural practices.
- Intervention programs should establish ties with religious and cultural leaders to promote the abandonment of FGM. Religious leaders can play an important role in discrediting the belief that FGM is a religious obligation.
- It is important to provide “safe houses” for girls who have escaped FGM or child marriage. The houses should provide women and girls with shelter, counseling, and reconciliation and reintegration programs.
- Government support is essential to ending harmful cultural practices. Anti-FGM laws are necessary, but largely ineffective without government support. Law enforcement officers should be trained to enforce anti-FGM laws and protect “uncircumcised” women and families from community harassment.
A local clinic in the Gambia run by the Foundation for Research on Women’s Health, Productivity and Development (BAFROW) created an innovative radio program to discourage FGM among the surrounding communities. With assistance from UNFPA, it broadcasted the voices of husbands speaking about the adverse health risks of FGM. The program served as one component of the clinic’s outreach strategy.30
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| 1 |
Laxminarayan R, Mills AJ, Breman JG, Measham AR, Alleyne G, Claeson M, et al. 2006. Advancement of global health: key messages from the Disease Control Priorities Project. Lancet 367:1193-208. |
| 2 |
UN Millennium Project. 2006. Public choices, private decisions: sexual and reproductive health and the Millennium Development Goals. New York: U.N. Millennium Project. |
| 3 |
Cleland J, Bernstein S, Ezeh A, Foundes A, Glasier A, Innis J. 2006. Family planning: the unfinished agenda. Lancet 368:1810-27. |
| 4 |
Low N, Broutet N, Adu-Sarkodie Y, et al. 2006. Global control of sexually transmitted infections. Lancet 368:2001-16. |
| 5 |
World Health Organization. 2005. World health report 2005: make every mother and child count. Geneva: WHO. Available from: www.who.int/whr/2005/en/ |
| 6 |
World Health Organization. Emergency contraception fact sheet. Available from: www.who.int/mediacentre/factsheets/fs244/en/ |
| 7 |
Singh S, Darroch JE, Vlassoff M, Nadeau J. 2003. Adding it up: the benefits of investing in sexual and reproductive health care. New York: The Alan Guttmacher Institute, UNFPA. Available from: www.unfpa.org/upload/lib_pub_file/240_filename_addingitup.pdf |
| 8 |
Barnett B, Stein J. 1998. Women's voices, women's lives: the impact of family planning. FHI. Available from: www.fhi.org/en/RH/Pubs/wsp/synthesis/index.htm |
| 9 |
Marston C. 2005. Report of a WHO technical consultation on birth spacing. Geneva: WHO. Available from: www.who.int/reproductive-health/publications/birthspacing/birth_spacing.pdf |
| 10 |
Dayaratna V, Winfrew W, McGreevey W, Hardee K. 2000. Reproductive health interventions: which ones work and what do they cost? The Policy Project. Washington, DC: United States Agency for International Development. Available from: www.policyproject.com/pubs/occasional/op-05.pdf |
| 11 |
United States Food and Drug Administration. Birth control guide.1997 Last updated August 2003. (accessed July 17, 2008), Available from: www.fda.gov/Fdac/features/1997/babytabl.html |
| 12 |
Nanda G, Switlick K, Lule E. 2005. Accelerating progress towards achieving the MDG to improve maternal health. World Bank. Available from here. |
| 13 |
United Nations Population Division. Surviving childbirth, but enduring chronic ill-health. (accessed August 16, 2007), Available from: www.endfistula.org/q_a.htm. |
| 14 |
Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. 2007. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 370:1358-69. |
| 15 |
World Health Organization. 2003. Antenatal care in developing countries: promises, achievements, and missed opportunities. Available from: http://who.int/reproductive-health/publications/antenatal_care/index.html |
| 16 |
Francisco A, Dixon-Mueller R, d'Arcangues C. 2007. Research issues in sexual and reproductive health for low- and middle- income countries. Geneva: Global Forum for Health Research. Available from: www.who.int/reproductive-health/publications/research/srh_lowmiddleincome_countries.pdf |
| 17 |
UNFPA. No woman should die giving life: facts and figures. (accessed July 14, 2008), Available from: www.unfpa.org/safemotherhood/mediakit/documents/fs/factsheet4_eng.pdf |
| 18 |
UNICEF. 2008. Progress for children: a report card on maternal mortality. Available from: www.unicef.org/childsurvival/files/Progress_for_Children-No._7_Lo-Res_082008.pdf |
| 19 |
Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha M, Anwar I, et al. 2006. Going to scale with professional skilled care. Lancet 368(9544):1377-86. |
| 20 |
World Health Organization. 1998. Postpartum care of the mother and newborn: a practical guide. Available from: https://www.who.int/reproductive-health/publications/msm_98_3/index.html |
| 21 |
Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua F, et al. 2006. Unsafe abortion: the preventable pandemic. Lancet 368:1908-19 |
| 22 |
Guttmacher Institute, World Health Organization. 2007. Facts on induced abortion worldwide. Available from: www.who.int/reproductive-health/unsafe_abortion/induced_abortion_worldwide.pdf |
| 23 |
World Health Organization. Mid-level health-care providers are a safe alternative to doctors for first-trimester abortions.2008 (accessed July 14, 2008), Available from: www.who.int/reproductive-health/hrp/policy_briefs/midlevel_hcproviders.pdf |
| 24 |
United Nations Population Division. State of the world population 2005: the promise of equality: gender equity, reproductive health and the Millennium Development Goals. New York: UNFPA. Available from: www.unfpa.org/swp/2005/pdf/en_swp05.pdf |
| 25 |
International Conference on Population and Development. Programme of Action.1993 (accessed, Available from: www.unfpa.org/icpd/icpd_poa.htm#ch4c |
| 26 |
Levack A. Working with boys and men to address reproductive health. Unmet needs in reproductive health July 25, 2007; Washington, DC: Global Health Council. http://www.globalhealth.org/images/pdf/events/a_levack.pdf |
| 27 |
Barker G, Ricardo C, Nascimento M. 2007. Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. Available from: www.who.int/gender/documents/Engaging_men_boys.pdf |
| 28 |
UNFPA. 2006. Ending violence against women: programming for prevention, protection and care. New York. |
| 29 |
World Health Organization. 2005. WHO multi-country study on women's health and domestic violence against women--initial results on prevalence, health outcomes and women's responses. Geneva: World Health Organization. Available from: www.who.int/gender/violence/who_multicountry_study/en/index.html |
| 30 |
UNFPA. 2007. A holistic approach to the abandonment of female genital mutlilation/cutting New York. Available from: www.unfpa.org/upload/lib_pub_file/726_filename_fgm.pdf |
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