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Sexual and Reproductive Health
| Definitions: |
Reproductive health is 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 and processes.1
Sexual health is defined as a state of physical, emotional, mental and social well-being in matters related to sexuality; it is not merely the absence of disease, dysfunction or infirmity.2
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Despite important gains, progress in achieving good reproductive health is very unevenly distributed. Poor women and men are the most in need and the least well served.3
Early and unwanted childbearing, HIV and other sexually transmitted infections (STIs), and pregnancy-related illnesses and deaths account for a significant proportion of the burden of illness experienced by women—especially women in low-income countries.4 Every year, 250 million years of productive life are lost due to death or disability related to poor sexual and reproductive health.5
Gender-based violence compromises the sexual and reproductive health of one in every three women.6-8 Many are unable to control decisions to have sex or to negotiate safer sexual practices, placing them at great risk of disease and health complications.6
The constructive engagement of men as partners and fathers in promoting good reproductive health for themselves and their partners requires far greater attention.6, 9 Men also need reproductive health information and services, STI prevention and treatment, and access to contraception. To ensure a healthy pregnancy and delivery, men need information about maternal health and nutrition, signs of illness or complications during pregnancy, and actions they can take.
Five core facts of sexual and reproductive health care are:9, 10
- More than half a million women die of pregnancy-related causes each year; about 10 million women suffer complications related to pregnancy or childbirth, many with lifelong consequences.11, 12
- In sub-Saharan Africa, high fertility in earlier decades will result in a dramatic (20 percent) increase in the number of women of reproductive age (15–44 years) by 2015.13 Total fertility rates in 32 countries remains at or above five births per woman; on average, only 12 percent of women in these countries use a modern method of contraception. Family planning services are, therefore, essential.
- In some low- and middle-income countries, up to half of hospital budgets allocated to obstetrics and gynecology are spent treating complications of unsafe abortion.14
- A billion STIs (one per every three adults) occur each year.9 Symptomatic and asymptomatic STIs can be passed to infants or result in infertility.
- In most developing countries, women lack the basic information and social support needed to make informed decisions regarding their sexual health.
Family Planning
Family planning is one of the most basic and essential health-care services. The ability to choose the number and spacing of their children promotes healthier mothers and children, as well as smaller families that are better able to meet their household’s economic needs. At least 200 million women in need lack access to modern methods of family planning.6
- In developing countries, family planning services and contraceptives are not accessible to millions of men and women. In many countries, past high fertility rates have resulted in an increase of women in their reproductive years (ages 15–44).
- The combination of an increase in population and low contraceptive use has increased the annual number of unintended pregnancies to 80 million in the developing countries.15
Family planning is an effective means to reduce maternal mortality by preventing unwanted pregnancy and unsafe abortion and by promoting healthy pregnancies (i.e., maternal age and parity, and birth spacing).16
Contraception
Contraceptive methods vary in their effectiveness, depending on their mechanism of action and consistency of use.17
- About 35 percent of all maternal deaths could be eliminated if all women and men had access to contraception to prevent unwanted pregnancies.18
- In sub-Saharan Africa, on average, only 23 percent of women use modern or traditional contraceptives. In some countries, the proportion even goes below 8 percent.13, 19
Contraceptive Effectiveness17
| Most Effective |
Effective |
Less Effective |
- Intrauterine device
- Implant
- Injectibles
- Sterilization
|
- Correct and Consistent Use of Oral Birth Control Pills
- Correct and Consistent Use of Condom
|
- Withdrawal
- Periodic Abstinence or Rhythm Method
|
Use of specific methods of contraception vary, influenced by personal preference for and availability of contraceptive methods, health practitioner preference, and the cost and consistency of methods.17, 20 This variability is found in developed and developing countries.
- Oral birth control pills are used by 60 percent of contraceptive users in Bangladesh but only 6 percent of those in India, where 78 percent of married couples resort to sterilization methods.13
- Intrauterine devices (IUDs) are used by 62 percent of contraceptive users in Egypt, but only 8 percent of contraceptive users in Morocco.13
Rate of contraceptive use is associated with wealth, education, ethnicity, place of residence, and strength of national family planning programs within countries.19 In 2005, average use of any method of contraceptive prevalence among married women aged 15–49 were as low as 13.4 percent in West Africa, 27.4 percent in all of Africa, while contraceptive prevalence in Asia was much higher at 63.3 percent. On average, the poorest women in society are four times less likely to use contraception than the wealthiest women – the disparity increases to a 12-fold difference in some countries.21 Contraceptive practices are governed by the government policies that promote the use of specific methods.
Click here for more information on contraceptives and use by region.
Fertility Trends
Over the past 40 years, there has been a decline in total fertility rates as effective, safe and affordable contraception has become available to more women and men. Unfortunately, this progress has been affected by reduced funding for contraceptive research and investments in family planning services.21 For example, at least 200 million couples who wish to space or delay their next birth still do not have access to modern methods of contraception.6, 22
Fertility is measured by calculating the total fertility rate, which is the average number of live births per woman during her reproductive years. The replacement fertility rate is 2.1 births per woman.23
Total Fertility Rates by UNICEF Region, 200623
Unsafe Abortion
An unsafe abortion is “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.”14
Pregnancies and Abortions6, 24
- Of the 205 million pregnancies each year, about 80 percent result in live births and 20 percent are voluntarily terminated.24 Of the 80 million unintended pregnancies, about half are voluntarily terminated.15
- Of the 20 million illegal or unsafe abortions each year, 97 percent occur in developing countries, resulting in 67,000 deaths.24 An estimated 62 percent of all deaths due to unsafe abortion take place in Asia (with a third of these occurring in China). More than half of all abortions performed in developing countries are considered unsafe; in Africa and Latin America 95 percent of abortions are unsafe. Illegal or unsafe abortions are often performed by unskilled providers under unsanitary conditions.9
Unsafe abortions can also result in long term disabilities that are not treated or recorded because poor women are unable to seek medical care. Reproductive tract infections (RTI) occur following about 20–30 percent of unsafe abortions; RTI is associated with pelvic inflammatory disease and infertility.25
Adolescents, unmarried girls and women who live in poverty, sparsely populated areas or vulnerable circumstances (such as refugees or internally displaced) are at higher risk of unsafe abortion.26, 27 These at-risk groups have less access to reproductive health information and services, and are often vulnerable to sexual coercion and violence. They may delay seeking abortion, and they are thus more likely to have to rely on unsafe abortion methods and unskilled providers or to experience complications.28, 29
There is regional variation in the number of deaths due to abortion, probably due to lack of awareness, inaccessible and unsafe of abortion services, lack of skilled health providers and legal restrictions surrounding the issue. The highest mortality rate occurs in Africa – 650 women out of every 100,000 with an abortion die.24 This level is 10 women per 100,000 in developed regions.
Sexual Health
Women may be uninformed about their sexual health, resulting in an underutilization of services and inadequate care. Providing information and counseling to women about their sexual and reproductive rights, combating gender-based violence and involving men in all health initiatives are key elements that will enable women to make informed decisions.
In 1968, at the World Conference on Human Rights at Tehran (Iran), ‘choice of reproduction’ was explicitly recognized as a human right.30 Later, the International Conference on Population and Development (ICPD) at Cairo, Egypt, in 1994, discussed the need to develop a human rights framework to address population and reproductive health issues.31
Gender-based Violence
Gender-based violence is the most common form of daily violence. Given the regularity of gender-based violence and its relative acceptance in some cultures, it may be overlooked.32 Overall, it is estimated that one in three women is subjected to one or more acts of physical, sexual or emotional violence during her lifetime.6
- In a multi-country study by the World Health Organization (WHO), it was reported that among developing countries, 41–72 percent of ever-partnered women reported physical abuse or sexual violence or both by an intimate partner in their lifetime. The highest levels were recorded in rural provinces of Ethiopia and Peru with 71 percent and 69 percent, respectively, and in urban Bangladesh where 62 percent of ever-partnered women reported physical abuse or sexual violence or both by an intimate partner.33
- Men who hold traditional views and attitudes about gender are associated with violence toward partners, more sexual partners, higher rates of STIs, lower condom use, and higher alcohol and drug use.34
- In Botswana, 30 percent of women admitted that their partners hold all of the power to decide whether or not to have sex; 53 percent of the women reported that their partners refused to use a condom during at least one sexual encounter in the previous year.35
- Forced sex and rape victims often report being violated not by strangers, but by men in their lives.36 Women who experience violence, particularly as adolescents, are more likely to engage in high-risk behaviors, such as selling sex or having multiple partners.37
- A woman in a violent relationship may have few options, particularly if property laws in her country do not recognize women as landowners, or if she lacks access to economic opportunities to provide food and shelter for herself and her family.
In sub-Saharan Africa and some parts of Southeast Asia, female genital mutilation or cutting is still practiced, often conducted on girls less than 10 years of age. Generally practiced in unsanitary conditions, acute hemorrhage and infection can occur in the short-term; long-term consequences include increased morbidity, including caesarean section, postpartum hemorrhage and a longer stay in the hospital after delivery.9
Adolescents are particularly at risk, given their lack of education, skills and money. Through sustained support by community members and policy-makers, efforts are needed to keep girls in school, educate them about sexual and reproductive health, provide for economic independence through vocational training and reverse gender discrimination on all fronts.6, 9
Gender inequalities render women more vulnerable to HIV/AIDS. Abused women are more likely to become infected with HIV/AIDS or an STI and abusive men are more likely to have sex with multiple partners.6, 38
- Women fearing violent retaliation are less likely to ask partners or husbands to use condoms or get tested or treated for HIV or STIs.37 Women seeking voluntary testing and counseling may face violent reactions after disclosing their HIV status to partners.39
- Risk of HIV transmission increases with the degree of trauma, vaginal lacerations and abrasions that occur when force is used. In addition, women who are violently abused are unlikely to have the ability to negotiate condom use.
- Women subjected to physical, sexual or psychological violence in Rwanda, Tanzania and South Africa were up to three times more likely to contract HIV than their female counterparts who had not been abused or treated violently.37
| 1 |
United Nations International Conference on Population and Development. Reproductive rights and reproductive health. Programme of action of the United Nations ICPD. 1994. (accessed April 29, 2008), Available from: www.iisd.ca/Cairo/program/p07002.html |
| 2 |
World Health Organization. WHO global burden of disease (GBD) 2002 estimates (revised). Available from: www.who.int/healthinfo/bodestimates/en/ |
| 3 |
Langer A. 2006. Cairo after 12 years: successes, setbacks, and challenges. Lancet 368:1552-5. |
| 4 |
United Nations. 1995. Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. New York. |
| 5 |
United Nations Population Fund. 2005. Reproductive health fact sheet. (accessed June 11, 2008), Available from: www.unfpa.org/swp/2005/presskit/factsheets/facts_rh.htm/ |
| 6 |
UN Millennium Project. 2006. Public choices, private decisions: sexual and reproductive health and the Millennium Development Goals. New York: U.N. Millennium Project. |
| 7 |
Garcia-Moreno C, Henrica J, Watts C, Ellsberg M, Heise L. 2005. WHO multi-country study on women’s health and domestic violence against women. Geneva: WHO. Available from: www.who.int/gender/violence/who_multicountry_study/summary_report/summary_report_English2.pdf |
| 8 |
WHO. 2002. World report on violence and health. Geneva. Available from: http://whqlibdoc.who.int/publications/2002/9241545615_eng.pdf |
| 9 |
Glasier A, Gulmezoglu A, Schmid G, Moreno C, Van Look P. 2006. Sexual and reproductive health: a matter of life and death. Lancet 368:1595-607. |
| 10 |
World Health Organization. 2004. Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Available from: www.who.int/reproductive-health/publications/zh/strategy_zh.pdf |
| 11 |
World Health Organization, UNICEF, UNFPA, World Bank. 2007. Maternal mortality in 2005. Available from: www.who.int/whosis/mme_2005.pdf |
| 12 |
Nanda G, Switlick K, Lule E. 2005. Accelerating progress towards achieving the MDGs to improve maternal health. World Bank. Available from here. |
| 13 |
Population Reference Bureau. 2008. Family planning worldwide: 2008 data sheet. Available from: www.prb.org/pdf08/fpds08.pdf |
| 14 |
Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua F, et al. 2006. Unsafe abortion: the preventable pandemic. Lancet 368:1908-19. |
| 15 |
Sedgh G, Henshaw H, Singh S, Ahman E, Shah IH. 2007. Induced abortion: estimated rates and trends worldwide. Lancet 370:1338-45 |
| 16 |
Marston C, Cleland J. 2004. The effects of contraception on obstetric outcome. Geneva: World Health Organization. Available from: www.who.int/reproductive-health/publications/2004/effects_contraception/text.pdf |
| 17 |
Cleland J, Bernstein S, Ezeh A, Foundes A, Glasier A, Innis J. 2006. Family planning: the unfinished agenda. Lancet 368:1810-27. |
| 18 |
All Party Parliamentary Group for Population Development and Reproductive Health. 2007. Return of the population growth factor: its impact upon the millennium development goals. Available from here. |
| 19 |
United Nations Population Division, UN Department of Economic and Social Affairs. 2005. World contraceptive use. New York: United Nations. |
| 20 |
UNFPA. Reducing risks by offering contraceptive services. Available from: www.unfpa.org/mothers/contraceptive.htm |
| 21 |
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 |
| 22 |
WHO. Promoting Family Planning. (accessed August 16, 2007), Available from: www.who.int/reproductive-health/family_planning/index.htm |
| 23 |
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 |
| 24 |
Guttmacher Institute, World Health Organization. 2007. Facts on induced abortion worldwide. Available from: www.guttmacher.org/pubs/fb_IAW.html |
| 25 |
World Health Organization. 2004. Unsafe abortion: global and regional estimates of unsafe abortion and associated mortality in 2000. Geneva: WHO. Available from: www.who.int/reproductive-health/publications/unsafeabortion_2000/estimates.pdf |
| 26 |
Gardner R, Blackburn R. 1996. People who move: new reproductive health focus. . . Population Reports Series (45). |
| 27 |
World Health Organization. 2005. World health report 2005: make every mother and child count. Geneva: WHO. Available from: www.who.int/whr/2005/en/ |
| 28 |
Mundigo A, Indriso C. 1999. Abortion in the developing world. New Delhi: World Health Organization. Available from: www.who.int/inf-pr-1999/en/pr99-28.html |
| 29 |
Warriner IK, Shah IH. 2006. Preventing unsafe abortion and its consequences: priorities for research and action. Guttmacher Institute. Available from: www.guttmacher.org/pubs/2006/07/10/PreventingUnsafeAbortion.pdf |
| 30 |
United Nations. Proclamation of Teheran. 1968. Available from: www.unhchr.ch/html/menu3/b/b_tehern.htm |
| 31 |
International Conference on Population and Development. 1993. Programme of Action. Available from: www.unfpa.org/ |
| 32 |
Kelly L, Radford J. Sexual Violence against women and girls: an approach to an international overview. In: Dobash R, Dobash R, editors. Rethinking violence against women. Thousand Oaks, California: Sage Press, 1998. |
| 33 |
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: WHO. Available from: www.who.int/gender/violence/who_multicountry_study/summary_report/summary_report_English2.pdf |
| 34 |
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 |
| 35 |
Physicians for Human Rights. 2007. Epidemic of inequality: women's rights and HIV/AIDS in Botswana & Swaziland: an evidence-based report on gender inequity, stigma and discrimination. Available from: http://physiciansforhumanrights.org/library/documents/reports/botswana-swaziland-report.pdf |
| 36 |
PATH, UNFPA. 2002. Violence against women: effects on reproductive health. Outlook. Available from: www.path.org/files/EOL20_1.pdf |
| 37 |
Global Coalition on Women and AIDS, World Health Organization. Intimate partner violence and HIV/AIDS. Information bulletin series: violence against women and HIV/AIDS: critical intersections. Available from: www.who.int/gender/violence/en/vawinformationbrief.pdf |
| 38 |
Garcia-Moreno C, Watts C. 2002. Violence against women: its importance for HIV/AIDS prevention. AIDS 24(3):S253-65. |
| 39 |
World Health Organization. 2004. Gender dimensions of HIV status disclosure to sexual partners: rates, barriers and outcomes. Geneva: WHO. Available from: www.who.int/gender/documents/en/genderdimensions.pdf |
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