Ambo university md Introduction to RH.pdf

Reproductive and maternal health
Bikila
1

History, concepts, definitions, components of
RH
2

Session Objectives:-
 At the end of the lesson the students will be able to
➢ Explain historical development of RH
➢ Define reproductive health
➢ Describe factors influencing Rh
➢ Describe reproductive health rights
➢ Explain reproductive health indicators
➢ Mention the global mentoring reproductive health indicators
3

Historical development of RH
✓Global concern about maternal and child health was evident as soon
as the WHO was established in 1948.
✓ The priorities of WHO at the outset was maternal and child health
alongside tuberculosis, malaria and venereal diseases.
✓ Following this the Primary Health Care (PHC) conference (Health For
All by the year 2000) made maternal and child health care as one of
the eight elements of PHC considering that the health of mothers and
children had not improved in any meaningful way.
4

Cont’d
 Elements of PHC:-
❑Education
❑Water and sanitation
❑Nutrition
❑Maternal and child health
❑Immunization
❑Prevention endemic disease
❑Treatment
❑Drug availability
5

Cont’d
❖ Following the implementation of the PHC strategy, it was noted that
improvement of maternal health was even greatly deficient.
❖ The world was faced with facts about the tragedy of unacceptable
high maternal mortality.
❖ Some extraordinary contributions were made in the form of
published articles in the 1980s including “Maternal Mortality a
Neglected Tragedy Where is the M in MCH?”.
❖ A global scheme known as “Safe Motherhood Initiative” was
introduced in 1987 .
❖ The primary aim of the Safe Motherhood initiative was to reduce
death and illnesses among women and infants in developing
countries by providing maternal health services to all women.
6

Cont’d
 The International Conference on Population and Development ICPD
(1994) and the Paradigm Shift:-
 During the time of the ICPD conference:-
▪ Almost 600,000 women died each year due to pregnancy-related
causes, 99% of them in developing countries.
▪ Lifetime risk of maternal death was estimated to be 1: 48 in developing
countries whereas it was 1:1800 in developed ones.
▪ There were about 7-8 million perinatal deaths each year.
▪ There were more than 330 million cases of curable sexually transmitted
diseases worldwide each year.
7

Cont’d…
✓About 60 million couples were infertile worldwide.
✓In 1994, the International Conference on Population and Development
(ICPD) in Cairo approved a new Program of Action as a guide for
national and international action in the area of population and
development for the next 20 years.
✓The conference came up with a big paradigm shift from previous world
conferences in its strategies to deal with population and development
based on the lessons learned from previous approaches.
8

Cont’d…
 The shift was also based on lessons learned from the various programs
that aimed at improving the health of mothers and children over many
decades.
 This paradigm shift was expressed in the following ways:
▪ Shift from population control and demographic targets towards a more
holistic approach to women’s health.
 Realization of the possibility to achieve a stabilization of world
9

Cont’d
 Recognition of the needs of people in sexuality and reproduction
beyond fertility regulation.
 Criticism of the over-emphasis on the control of female fertility.
 Radical shift away from technology-based, top-down approaches to
program planning and implementation.
10

Cont’d
 The 1994 ICPD has been marked as the key event in the history of
reproductive health.
 The impetus behind the paradigm shift:-
▪ The growing strength of the women’s movement.
▪ The advent of the HIV/AIDS pandemic.
▪ An interpretation of international human rights treaties in terms of
women’s health in general and reproductive health in particular
gradually gained acceptance during the 1990s.
11

Cont’d
 The Pre- International Conference on Population and
Development (ICPD, m1994) period
 The first conference in Rome (1954):-
❑Population growth and its consequences were expressed using terms
such as “standing room only”, “population bombs”, “demographic
entrapment” and scarcity of food, water and renewable resources.
 The second conference Belgrade:-
❑ Emphasized analysis of fertility as part of a policy for development
planning and coincided with the start-up of population programs
12

Cont’d
❑The 1974 Bucharest, Romania stated that population variables and
development are interdependent and that population policies and
their objectives are an integral part of socio economic development
policies.
❑ The next world population conference took place in Mexico City in
August 1984.
❑It reviewed and endorsed most aspects of the agreements of the
1974 Bucharest conference and expanded the World Population Plan
13

cont’d
▪ In 1972, WHO established the Special Program of Research,
Development and Research Training in Human Reproduction
(HRP).
▪ whose mandate was focused on research into the development
of new and improved methods of fertility regulation and issues of
safety and efficacy of existing methods.
14

The Post-Cairo Period
 Progress and challenges in the first five years of implementing the Cairo agreement
were the focus of a series of meetings including a special session of the United
Nations General Assembly (ICPD+5) in June 1999.
 Five years after ICPD these main achievements and challenges were thus identified:
 Achievements:-
 Concept adopted by most countries.
 New policies and programs defined (e.g., India’s target-free reproductive and child
health program).
15

Cont’d
 New partnerships formed (e.g., greater NGO participation;
public/private partnerships).
 New evidence collected (e.g., burden of disease due to reproductive
ill-health; best practices; gender-based violence).
 Challenges:-
 Patchy implementation of holistic and integrated programs
 Uncoordinated, fragmented approaches by multiple players.
 Failure to scale up from projects to sustainable programs
16

Cont’d
 Weak health systems (health sector reform).
 Relative neglect of RH by new development instruments (e.g. SWAPs,
PRSPs, Global Fund, and others.) and;
 “Competition” from “other” programs. (e.g., HIV/AIDS).
17

Cont’d
 Key Actions to Carry Further Implementation of the Program of Action
of the ICPD including setting new benchmark indicators of progress in
four key areas:
 Education and literacy:-
▪ Achieving universal access to primary education;
▪ eliminate the gender gap in primary and secondary education by
2005.
▪ Primary school enrolment ratio 90% by 2010 for both sex
▪ Reduce the rate of illiteracy by half by 2005 from the 1990
18

Cont’d
 Reproductive health care and unmet need for contraception:-
▪ Ensure that by 2015 all primary healthcare and family planning
facilities are able to provide, widest achievable range of safe and
effective family planning.
▪ Provide essential obstetric care; prevention and management of
reproductive tract infections.
▪ By 2005, 60 per cent of such facilities should be able to offer this
range of services, and by 2010, 80 per cent of them should be able to
offer such services."
▪ CPR and unmet need by 50 per cent by 2005, 75 per cent by 2010
19

Cont’d
 Maternal mortality reduction:-
▪ All births should be assessed by skill birth attendant by 2005, 80%, by
2010, 85 per cent, and by 2015, 90 per cent."
▪ For countries where maternal mortality high 40, 50 and 60 per cent
respectively.
 HIV/AIDS:-
▪ young men and women aged 15 to 24 have access to the information,
education and services necessary to develop the life skills required to
reduce their vulnerability to HIV infection.
20

ICPD at 10
 The UN General Assembly commemorated the Tenth Anniversary of
ICPD in October 2004
 The Conference admired the progress while acknowledging the
challenge that many countries may fall short of achieving the agreed
upon goals and the commitments of to its Program of Action by
reaffirming the Program of Action of the International Conference on
Population and Development and the calling for key measures to be
implemented further.
21

Cont’d
 In the same way, African ministers responsible for population and
development, who met in Dakar, Senegal, on 11 June 2004, welcomed
with satisfaction the ten-year review of ICPD POA, pointed out the
constraints encountered and showed the way forward.
 They reaffirmed the need to achieve gender equality, equity and the
empowerment of women as highly important ends in themselves and key
to breaking the cycle of poverty and improving the quality of life of the
people of the continent.
22

Cont’d
 Achieving the MDG Goals by 2014 and Beyond
 The review found the commitment of governments, UN and
others stakeholders appreciable and progressive since ICPD.
 It also identified gaps that needed to be taken care of and made
suggestions for improvement in these areas:-
❑Eradicating Poverty
❑Gender Equality:
❑Massive violation of human rights of women and girls
23

Development of reproductive health
 Before 1978 Alma-Ata Conference
 Basic health services in clinics and health centers
 Primary health care declaration 1978
 MCH services started with more emphasis on child survival
 Family planning was the main focus for mothers
24

Cont’d
 Safe motherhood initiative in 1987
 Emphasis on maternal health
 Emphasis on reduction of maternal mortality
 Reproductive health, ICPD in 1994
 Emphasis on quality of services
 Emphasis on availability and accessibility
 Emphasis on social injustice
 Emphasis on individuals woman's needs and rights
25

cont’d
 Millennium development goals and reproductive health in
2000
 MDGs are directly or indirectly related to health
 MDG 4, 5 and 6 are directly related to health, while MDG 1,2,3,
and 7 are indirectly related to health
 World Summit 2005, declared universal access to reproductive
health
26

Cont’d
 Goal 3: Promote Gender Equality and Empower Women
 Target 3.A: Eliminate gender disparity in primary and secondary
enrolment, preferably by 2005, and in all levels of education no later
than 2015.
 Indicator 3.1: Ratios of girls to boys in primary, secondary and tertiary
education.
 Indicator 3.2: Share of women in wage employment in the non-
agricultural sectors.
27

Cont’d
 Goal 4: Reduce child mortality
 Target 4.A: Reduce by two-thirds, between 1990 and 2015, the under-
five mortality rate.
 Indicator 4.1: under-five mortality rate.
 Indicator 4.2: infant mortality rate.
 Indicator 4.3: proportion of 1 year-old children immunized against
measles.
28

Cont’d
 Goal 5: Improve maternal health
 Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality
ratio
 Indicator 5.1: Maternal mortality ratio
 Indicator 5.2: Proportion of births attended by skilled health personnel
 Target 5.B: Achieve, by 2015,universal access to reproductive health
 Indicator 5.3: Contraceptive prevalence rate
 Indicator 5.4: Adolescent birth rate Indictor
 5.5: Antenatal care coverage (at least one visit and at least four visits)
 Indicator 5.6: Unmet need for family planning
29

Cont’d
 Goal 6: Combat HIV/AIDS, malaria and other diseases
 Target 6.A: Have halted by 2015 and begun to reverse the spread of
HIV/AIDS
 Indicator 6.1: HIV prevalence among population aged 15-24 years
 Indicator 6.2: Condom use at last high-risk sex
 Indicator 6.3: Proportion of population aged 15-24 years with
30

Cont’d
 Following the MGD’s the sustainable development goals appears
 The sustainable development goals (SDGs) are a new, universal set of
goals, targets and indicators that UN member states will be expected
to use to frame their agendas and political policies over the next 15
years.
 Why we need other goals???
31

Cont’d
 Why do we need another set of goals?
 MDGs were too narrow.
 The eight MDGs – failed to consider the root causes of poverty and
overlooked gender inequality as well as the holistic nature of development.
32

Cont’d
▪ The goals made no mention of human rights and did not specifically
address economic development
▪ While the MDGs, in theory, applied to all countries, in reality they were
considered targets for poor countries to achieve, with finance from wealthy
states.
▪ As the MDG deadline approaches, about 1 billion people still live on less than
$1.25 a day
▪ The World Bank measure on poverty – and more than 800 million people do not
have enough food to eat.
▪ Women are still fighting hard for their rights, and millions of women still die in
childbirth.
33

Cont’d
 What are the proposed 17 goals?
1) End poverty in all its forms everywhere
2) End hunger, achieve food security and improved nutrition, and promote
sustainable agriculture
3) Ensure healthy lives and promote wellbeing for all at all ages
4) Ensure inclusive and equitable quality education and promote lifelong
learning opportunities for all
5) Achieve gender equality and empower all women and girls
6) Ensure availability and sustainable management of water and sanitation
34

Cont’d
10) Reduce inequality within and among countries
11) Make cities and human settlements inclusive, safe, resilient and
sustainable
12) Ensure sustainable consumption and production patterns
13) Take urgent action to combat climate change and its impacts (taking
note of agreements made by the UNFCCC forum)
14) Conserve and sustainably use the oceans, seas and marine resources
for sustainable development
15) Protect, restore and promote sustainable use of terrestrial ecosystems,
35

Cont’d
16) Promote peaceful and inclusive societies for sustainable development,
provide access to justice for all and build effective, accountable and
inclusive institutions at all levels
17) Strengthen the means of implementation and revitalize the global
partnership for sustainable development
36

Definition of Reproductive Health
 ICPD (1994) defined Reproductive Health as a state of complete physical mental and social
wellbeing and not merely the absence of disease or infirmity, in all matters related to the
reproductive system and its functions and processes.
 This definition implies:-
➢ People are able to have a satisfying and safe sex.
➢ The capability to reproduce and the freedom to decide if, when and how often to do so.
➢ The right of men and women to be informed of and to have access to safe, effective,
affordable and acceptable methods of family planning of their choice, as well as other
methods of their choice for regulation of fertility
37

Cont’d
 The three fundamental principles of sexual health are:
1) Capacity to enjoy and control sexual and reproductive behavior
2) Freedom from shame, guilt, fear, and other psychological factors that may
impair sexual relationships; and
3) Freedom from organic disorder or disease that interferes with sexual and
reproductive function.
38

Cont’d
▪ Sexual health is the integration of emotional, intellectual, and social
aspects of sexual being in order to positively enrich personality,
communication, relationships and love.
▪ Reproductive health contributes enormously to physical and
psychosocial comfort and closeness between individuals.
▪ Poor reproductive health is frequently associated with disease, abuse,
exploitation, unwanted pregnancy, and death.
39

Cont’d
▪ Healthy sexuality is a vital component of reproductive health
▪ Every sex act should be free of coercion and infection.
▪ Every pregnancy should be intended and every birth healthy.
▪ Healthy sexuality should include the concept of volition and informed
decision-making.
40

Reproductive Health Care
 Reproductive health care is defined as the constellation of methods,
techniques and services that contribute to reproductive health and
wellbeing by preventing and solving reproductive health problems.
 Objectives of Reproductive Health Care
 (a) To ensure that comprehensive and factual information and a full
range of reproductive health care services, including family planning, are
accessible, affordable, acceptable and convenient to all users.
41

Cont’d
(b)To enable and support responsible voluntary decisions by people about
childbearing and methods of family planning of their choice, as well as
other methods of their choice for regulation of fertility which are not
against the law and to have the information, .education and means to do
so
(c)To meet changing reproductive health needs over the life cycle and to
do so in ways sensitive to the diversity of circumstances of local
communities
42

Components of Reproductive Health Care
 In the context of primary health care, reproductive health care consists of
at least the following components:
❖ Family-planning counselling, information, education, communication and
services.
❖ Education and services for prenatal care, safe delivery and post-natal
care, especially breast-feeding and infant and women's health care.
43

Cont’d
❖ Prevention and appropriate treatment of infertility
❖ Prevent abortion and the management of the consequences of abortion;
treatment of RTI; STD and other reproductive health conditions.
❖ Safe abortion services where not against the law
❖ Information, education and counseling, as appropriate, concerning
sexuality, reproductive health and responsible parenthood.
44

Cont’d
❖Referral for family planning services and further diagnosis and
treatment for complications of pregnancy, delivery, abortion, infertility,
reproductive tract infections, breast cancer and cancers of the
reproductive system, sexually transmitted diseases, including HIV/AIDS
should always be available, as required.
❖Active discouragement of harmful practices, like female genital
mutilation, should also be an integral part of primary health care, as well
as including reproductive healthcare programs
45

Enabling Conditions for RH
 The International Conference on Population and Development
(ICPD 1994) identified the following enabling conditions for
reproductive health:-
 EmpoweringWomen and Promoting Gender Equality and Equity:-
 The goal should be to eliminate all forms of discrimination against women in order for
them to exercise their rights to sexual and reproductive health and participate equally at
all levels of political and public life.
 Eliminating Discrimination against the Girl Child:
 All forms of discrimination against the girl child and the reasons for causes of son
preferences, which result in harmful and unethical practices regarding female
46

Cont’d
 Ensuring Male Responsibility and Participation:
 Men play a key role in the achievement of gender equality because, in most societies,
their power is supreme in almost all spheres of life.
 Achieving Universal Education:-
 Progress in education contributes to reduction in fertility, morbidity and mortality; the
empowerment of women; improvement in the quality of life; and the promotion of genuine
democracy and respect for, and the exercise, human rights and fundamental freedoms.
 Increasingly the education of girls and women leads to the postponement of the age at
marriage,reduction in family size, and child survival
47

Cont’d
 In addition the attainment of reproductive health by populations
requires:
❑An enabling environment - politically, legally and culturally;
❑The empowerment of individuals with knowledge on how to promote
and protect their own reproductive health;
❑The provision of a wide-range of high quality health services -
accessible, appropriate, affordable and effective.
48

Factors affecting reproductive health
 Reproductive health affects, and is affected by, the broader context of
people's lives, including :-
❑ Economic circumstances
❑ Education
❑ Employment
❑ living conditions and family environment
❑ Social and gender relationships,and
❑ The traditional and legal Structures within which they live.
49

Cont’d
❑ Sexual and reproductive behaviors are governed by complex
biological, cultural and psychosocial factors.
❑ Therefore, the attainment of reproductive health is not limited to
interventions by the health sector alone.
❑ Nonetheless, most reproductive health problems cannot be
significantly addressed in the absence of health services and
medical knowledge and skills.
50

The importance of reproductive health
➢ Reproductive health is a crucial part of general health and a central
feature of human development.
➢ It is a reflection of health during childhood, and crucial during
adolescence and adulthood, sets the stage for health beyond the
reproductive years for both women and men, and affects the health
of the next generation
51

Cont’d
➢ Reproductive health is a universal concern, but is of special importance
for women particularly during the reproductive years.
➢ Although most reproductive health problems arise during the
reproductive years, in old age general health continues to reflect earlier
reproductive life events
➢At each stage of life individual needs differ. However, there is a
cumulative effect across the life course þ events at each phase having
important implications for future well-being.
52

Cont’d
➢ Failure to deal with reproductive health problems at any stage in life sets
the scene for later health and developmental problems.
➢ Because reproductive health is such an important component of general
health it is a prerequisite for social, economic and human development.
➢ The highest attainable level of health is not only a fundamental human
right for all, it is also a social and economic imperative because human
energy and creativity are the driving forces of development.
53

Human Rights and Reproductive Rights
 Reproductive rights embrace certain human rights recognized in
national and international legal and human rights documents.
 Some examples of the application of human rights to reproductive
health
1.Right to life:
 promote safe motherhood and advocate against maternal mortality and
morbidity, infanticide, genocide, and violence.
2.The right to Liberty and Security of the Person:
 protection of women and children from sexual abuse and such practices
as female genital mutilation
54

Cont’d
 3.Right to be free from all forms of discrimination:
➢Discrimination with regard to access to sexual and reproductive
health services
➢Discrimination that denies legal protection against violence.
➢Campaign for laws prohibiting discrimination against women and
work for their effective enforcement.
55

Cont’d
 4.Right to information and education:
➢ Allow the youth having access to information and education
➢ Give accurate information to enable service users to make decisions
on the basis of full, free, and informed consent
➢Discourage programs which do not give full information on the relative
benefits, risks, and effectiveness of all methods of fertility regulation.
56

Cont’d
 5. Right to be free from torture and ill Treatment:
➢ Protect women and children from sexual exploitation, prostitution
➢ Protect women and children from sexual abuse, coercion in any
sexual activity, and domestic violence
➢ Amend legislation which prohibits abortion on the grounds of rape.
57

Cont’d
6.The right to privacy:
➢All sexual and reproductive health care services should be confidential.
7.The right to freedom of thought:
➢Freedom from the restrictive interpretation of religious texts, beliefs,
philosophies and customs as tools to curtail freedom of thought about
sexual and reproductive health care.
58

Cont’d
 The International Planned Parenthood Federation (IPPF) in addition to the above
rights includes the following as a sexual and Reproductive rights:-
 The Right to Choose Whether or Not to Marry and to Found and Plan a Family:-
➢ Recognizes that all persons have the right to protection against a requirement to
marry without that person’s full, free and informed consent.
 The Right to Health Care and Health Protection:-
➢ Includes the right of health care clients to the highest possible quality of health care,
and the right to be free from traditional practices which are harmful to health.
59

Cont’d
 The Right to Decide Whether or When to Have Children:-
➢ Recognizes that all persons have the right to decide freely and
responsibly the number and spacing of their children and to have
access to the information, education and means to enable them to
exercise this right and further recognizes that special protection
should be accorded to women during a reasonable period before
and after childbirth.
60

Cont’d
 The Right to the Benefits of Scientific Progress:-
➢ Includes the right of sexual and reproductive health service clients to new
reproductive health technologies that are safe, effective and acceptable.
 The Right to Freedom of Assembly & Political Participation:-
➢ Includes the right of all persons to seek to influence communities and governments to
prioritize sexual and reproductive health and rights
61

The life cycle approach of Reproductive health
 THE LIFE CYCLE PERSPECTIVE
 Reproductive health is important for healthy social, economic, and
human development!
o Reproductive health is a crucial feature of healthy human
development and of general health.
o It may be a reflection of a healthy childhood, is crucial during
adolescence, and sets the stage for health in adulthood and beyond
the reproductive years for both men and women.
62

Cont’d
o Reproductive life span does not begin with sexual development at puberty and end at
menopause for a woman or when a man is no longer likely to have children.
o Rather, it follows throughout an individual’s life cycle and remains important in many
different phases of development and maturation.
o At each stage of life, individual reproductive health needs may differ.
o However, there is a cumulative effect across the life course, and each phase has
important implications for future well-being.
o An inability to deal with reproductive health problems at any stage in life may set the
scene for later health problems. This is known as the life cycle perspective for
63

Cont’d
 Reproductive health is a lifetime concern for women and men, from infancy to old age.
 In many cultures, discrimination against girls and women that begins in infancy can
determine the trajectory of their lives.
 Critical Messages for Different Life Stages that can empower men and women:-
 Girls and Boys
✓ Delay pregnancy
✓ Inspire and motivation to be sexually responsible partner
✓ Responsibility for the human catastrophe of orphans and other children who live in the
streets
64

Cont’d
 Adolescents:-
✓Integrated reproductive health education and services for young
people should include family planning information, and counseling
on gender relations, STDs and HIV/AIDS, sexual abuse and
✓Ensure that health care programs and service providers' attitudes
allow for adolescents' access to the special services and information
they need.
65

Cont’d
✓Support efforts to eradicate female genital cutting and other harmful
practices, like early or forced marriage, sexual abuse, and trafficking of
adolescents for forced labor, marriage or commercial sex.
✓Socialize and motivate boys and young men to show respect and
responsibility in their sexual relations.
66

Cont’d
 Adults:-
✓ Improve communication on issues of sexuality and reproductive health, and the
understanding of their joint responsibilities so that they are equal partners in public
and private life.
✓ Enable women to exercise their right to control their own fertility and their right to
make decisions concerning reproduction
✓ Improve the quality and availability of reproductive health care services and
barriers to access.
67

Cont’d
✓ Make emergency obstetric care available to all women who experience
complications in their pregnancies.
✓ Encourage men's responsibility for sexual and reproductive behavior
and increase male participation in family planning.
68

Cont’d
 The Older Years :-
✓ Reorient and strengthen health care services to better meet the needs of older women.
✓ Support outreach by women's NGOs to help older women in the community to better
understand the importance of girls' education, their reproductive rights and sexual
health so that they may become effective transmitters of such knowledge and practices.
✓ Develop strategies to better meet the needs of the elderly for food, water, shelter,
social and legal services and health care
69

Reproductive health indicators
▪ A health indicator is usually a numerical measure which provides information about a
complex situation or event.
▪ Indicators are markers of health status, service provision or resource availability,
designed to enable the monitoring of service performance or program goals.
▪ An indicator is a specific, observable and measurable characteristic that can be used
to show changes or progress a program is making toward achieving a specific
outcome.
▪ Indicators are expressed in terms of rates, proportions, averages, categorical
variables or absolute numbers.
70

Cont’d
▪ They can be useful tools for assessing needs, monitoring and evaluating program
implementation and impact
▪ Needs assessment: to assess the current status of reproductive health in the population
or in a specific sub-group
▪ Monitoring: to monitor the implementation and outputs of a program to ensure it is on-
track,or to monitor policy commitment
▪ Evaluation: to evaluate the effectiveness and impact of a program aimed at improving
reproductive health and/or achieving specific targets
71

Cont’d
The WHO distinguishes three dimensions of reproductive health:
 As a human condition (including the level of health and related areas of
wellbeing)
 As an approach (policies,legislation and attitudes);
 And as services (the provision of services, access to them, and their utilization).
72

Cont’d
 There are several indicator to measure reproductive health indicators
selected by different criteria.
 The selection criteria for indicators by being:-
➢ Ethical
➢ Useful
➢ Scientifically robust
➢ Representative
➢ Understandable, and
➢ Accessible
73

Key performance information concepts for M & E

74

75
Cont’d
Long-
term Goal
(Impact) Outcomes
Long-term,
widespread
improveme
nt in
society
behavior
changes
resulting
from
program
outputs
Outputs Activities Inputs
Products
and services
to be used
to simulate
the
achievemen
t of results
Utilization
of resources
to generate
products
and services
Resources
committed
to
program
activities
Results Implementation
PLANING FOR RESULTS
Results-based M&E

Cont’d
 WHO experts identified a short list of indicators for monitoring
reproductive health at national and international levels. The most
widely used ones are defined below:-
1.Total Fertility Rate:
➢ Total number of children a woman would have by the end of her
reproductive period, if she experienced the currently prevailing
age-specific fertility rates throughout her childbearing life.
78

Cont’d
➢ It is closely associated with contraceptive prevalence and other
indicators of reproductive health such as the maternal mortality
ratio.
➢ It is a useful indicator of population momentum and a good
proxy measure for the success (or failure) of family planning
services.
➢ The TFR may also be used as a measure of poor physical
79

Cont’d
2. Contraceptive Prevalence:
➢ The percentage of women of reproductive age who are using (or
whose partner is using) a contraceptive method at a particular point in
time.
➢ This indicator is useful for measuring utilization of contraceptive
methods
80

Cont’d
3.Maternal Mortality Ratio:
 The number of maternal deaths per 100 000 live births from causes
associated with pregnancy and child birth.
▪ Maternal mortality is widely acknowledged as a general indicator of
the overall health of a population, of the status of women in society and
of the functioning of the health system.
81

Cont’d
▪ It is therefore useful for advocacy purposes, in terms both of drawing
attention to broader challenges faced by governments and of safe
motherhood.
▪ This indicator can show the magnitude of the problem of maternal
death in a country as a stimulus for action.
82

Cont’d
4.Antenatal Care Coverage:
➢ The percentage of women attended, at least once during pregnancy, by skilled
health personnel for reasons related to pregnancy.
➢ The main purpose of an indicator of antenatal care 1-visit coverage is to provide
information on proportion of women who use antenatal care services.
➢ The finding that women who attend ANC are also more likely to use skilled health
personnel for care during birth and that ANC may facilitate better use of
emergency obstetric services is also further support for the use of this indicator in
combination with the indicator“skilled attendant at delivery”.
83

Cont’d
5. Births Attended by A Skilled Health Personnel:
➢ The percentage of births attended by skilled health personnel. This
doesn’t include births attended by traditional birth attendants.
➢ Both births attended by skilled personnel and antenatal care coverage
are measures of health care utilization; they provide information on
actual coverage (the effective population that receives the care).
84

Cont’d
➢ The indicator helps program management at district, national and
international levels by indicating whether safe motherhood programs
are on target in the availability and utilization of professional
assistance at delivery.
➢ In addition, the proportion of births attended by skilled personnel is a
measure of the health system’s functioning and potential to provide
adequate coverage for deliveries.
85

Cont’d
6.Availability of Basic Essential Obstetric Care:
The number of facilities with functioning basic essential obstetric care
per 500 000 population.
7.Availability of Comprehensive Essential Obstetric Care:
The number of facilities with functioning comprehensive essential
obstetric care per 500 000 population.
86

87
cont’d
 Theoretical pathway associating the availability of EOC services with maternal
mortality:-
Informati
on about
services
Motivatio
n to seek
care
Money
Time
Transpor
tation
Availabili
ty of
services
Timel
y use
of
good-
qualit
y
servic
es
Appropriat
e
manageme
nt of life-
threatening
obstetric
conditions
Reductio
n in
maternal
mortality

Cont’d
8.Perinatal Mortality Rate:
➢ The number of perinatal deaths (deaths occurring during late
pregnancy, during childbirth and up to seven completed days of life) per
1000 total births.
➢ Perinatal mortality is associated with poor maternal health.
➢ It provides useful insight into the quality of intrapartum and immediate
postnatal care and may be used as a good proxy measure of the quality
88

Cont’d
 It has been suggested as an alternative and more sensitive measure of
maternal health status, since the ascertainment of perinatal death is less
difficult than that of maternal morbidity.
9.Low Birth Weight Prevalence:
 The percentage of live births that weigh less than 2500 g.
89

Cont’d
➢ Although duration of pregnancy is the most important determinant of
weight at birth, many other factors contribute.
➢ The rate of LBW is a rough summary measure of many factors,
including maternal nutrition (during childhood, adolescence, pre-
pregnancy and pregnancy), lifestyle (e.g. alcohol, tobacco and drug
use) and other exposures in pregnancy (e.g. infectious diseases and
altitude)
➢ LBW is strongly associated with a range of adverse health outcomes,
such as perinatal mortality and morbidity, infant mortality, disability
and disease in later life.
90

Cont’d
 10.Positive Syphilis Serology Prevalence in Pregnant Women;
➢ The percentage of pregnant women (15–24) attending antenatal clinics,
whose blood has been screened for syphilis, with positive serology for
syphilis.
➢ At the national and international levels, this indicator is useful as a proxy
of the burden of sexually transmitted infections (STI) in the general
population, and also as a marker of progress towards reducing the
burden of STI.
91

Cont’d
11.Prevalence of Anemia in Women:
➢ The percentage of women of reproductive age (15–49) screened for
hemoglobin levels with levels below 110 g/l for pregnant women and
below 120 g/l for non-pregnant women.
➢ It can be used as a proxy measure of general nutritional status or as a
direct measure of health status, since anemia is directly injurious to
health and is an important contributor to morbidity and mortality.
92

Cont’d
12.Percentage of Obstetric and Gynecological Admissions owing to Abortion:
➢ The percentage of all cases admitted to service delivery points providing in-
patient obstetric and gynecological services, which are due to abortion
(spontaneous and induced, but excluding planned termination of pregnancy).
➢ This indicator can be used to describe conditions at one point in time only.
➢ The best use of the indicator is as a measure of case-load (or cost or resource
demand) imposed on the medical system by complications of abortion. It can
be conceived as a process indicator for measuring utilization of services in
cases of abortion complications.
93

Cont’d
13.Reported Prevalence of Women with FGM:
The percentage of women interviewed in a community survey, and
reporting to have undergone FGM.
 FGM has a direct injurious effect on reproductive health.
 Reducing its prevalence is thus a marker of progress towards improved
94

Cont’d
14.Prevalence of Infertility in Women:
➢ The percentage of women of reproductive age (15–49) at risk of
pregnancy (not pregnant, sexually active, non-contraception and non-
lactating) who report trying for a pregnancy for two years or more.
➢ While infertility and its emotional and social consequences can have a
serious negative effect on reproductive health status, appropriate
treatment may be unavailable or expensive.
➢ Effective safe motherhood and STI prevention programs can
95

Cont’d
15.Reported Incidence of Urethritis in Men:
➢ The percentage of men (15–49) interviewed in a community survey,
and reporting at least one episode of urethritis in the last 12 months.
➢ This indicator is useful as a measure of the impact of preventive
services for sexually transmitted infections (STI). It also provides an
indication of the perceived burden of STI on the adult male population,
as it measures the reported prevalence of a major STI symptom in
men.
➢ Urethritis is discharge from the penis, with or without a burning
sensation or pain while passing urine.
96

Cont’d
16.HIV Prevalence in Pregnant Women:
➢ The percentage of pregnant women (15–24) attending antenatal clinics,
whose blood has been screened for HIV, and who are sero-positive for
HIV.
➢ This indicator is used as a proxy for HIV incidence.
➢ The incidence of HIV infection is the preferred indicator to monitor the
course of the HIV epidemic and the impact of interventions; prevalence
data are of limited value since they reflect infections acquired over a
number of years.
➢ In the case of this indicator, incidence is estimated from prevalence data
in young women; prevalence in this age group is likely to reflect
infections that have occurred recently.
97

Cont’d
17.Knowledge of HIV-related Prevention Practices:
➢ The percentage of all respondents who correctly identify all three major ways of
preventing the sexual transmission of HIV and who reject the three major
misconceptions about HIV transmission or prevention.
➢ Knowledge of preventive practices in HIV/AIDS is a prerequisite for behavioral change.
Originally, the indicator consisted only in correctly identifying HIV prevention
practices, with the underlying rationale that improved knowledge of such practices is a
precondition to constructive behavioral change.
98

Reproductive Health in Ethiopia
▪ Although Ethiopia has designed and implemented various policies
and strategies and programs and improvements have been noted.
▪ Deaths from reproductive health associated causes are high as
evidenced by high maternal and infant mortality and morbidity
rates.
▪ Reproductive health status is determined by poor economic status
(poverty), educational status (particularly that of women and girls),
the legal environment, provision of health care (RH strategy
document).
99

Cont’d
▪ Reproductive health service coverage remains low although there
have been considerable improvements in utilization of some services
like family planning.
▪ Women’s status both in the community and in the household is low,
constrained by a patriarchal family system dominated by men and by
elders.
▪ Gender discrimination starts from birth and decision making in the
household is dominated by males
100

Cont’d
▪ Research has shown that women’s education delays marriage and first birth,
increases FP use, improves communication with partners and advances
women’s status in the community.
▪ Although girls’ enrollment in school has increased significantly, it still falls well
behind that of boys; and girls are significantly less likely than boys to continue
their schooling to high school completion.
▪ Employment in paid jobs in the formal economy is significantly lower for
women than men.
▪ Finally, exposure to the media, while generally low, is significantly lower for
women, providing less opportunity for access to information that might be
useful.
101

RH Indicators in Ethiopia
 Indicators
✓ Total fertility rate -------------------------------------------4.6
✓ Contraceptive prevalent rate any modern method -----41%
✓ Contraceptive prevalent rate modern ------------------35%
✓ Maternal mortality ration ---------------------------------412/100,000
✓ Antenatal care by a skilled provider ---------------------74%
✓ Birth attended by skilled personal -----------------------48%
✓ Adolescent birth rate ----------------------------------------13%
✓ neonatal mortality ------------------------------------------- 30
✓ Infant mortality ------------------------------------------------43
✓ Under five mortality -------------------------------------------55
102

Cont’d
▪ Over the past 20 years, the government of Ethiopia has followed up
on its international commitments by adopting and implementing a
series of policies and national strategies
▪ aimed at creating the necessary conditions for all Ethiopians to have
access to basic social services as well as ensuring women’s human,
economic, and political rights and their full participation in the
development process.
103

cont’d
 Global and national policy environment
 The Ethiopian Government is a signatory to several International
Conventions/Charters and Declarations including those arising
from:-
• Safe Motherhood Conference in Nairobi in 1987;
• World Summit for Children in 1990;
• International Conference on Population and Development (ICPD) in
1994
• (FP is one of the eight ICPD priority actions)
104

Cont’d
▪ Fourth World Conference for Women in 1995;
▪ Convention on Elimination of all forms of Discrimination against
Women (CEDAW);
▪ Millennium Declaration
▪ The UN Human Rights Charter
▪ Declaration on the Elimination of Violence Against Women
(DEVAW).
105

Cont’d
 Strategies related to RH:-
1. Strengthen and expand community and facility-based maternal,
newborn, child and adolescent health services.
 1.1. Scale up family planning program (through community based FP
services, social marketing, facility based and outreach long acting and
permanent FP service provision)
 1.2. Scale up of midwifery training.
 1.3. Scale up Basic Emergency Obstetric and Newborn Care
(BEmONC), Comprehensive Emergency Obstetric and Newborn Care
(CEmONC
106

Cont’d
 1.4. Conduct maternal death Auditing.
 1.5. Service Integration with emphasis on RH-HIV integration, (in
particular FP-HIV prevention linkages through common messages and
dual protection) and harmonized approach among all partners.
 1.6. Enhance the referral system including pediatric referral.
 1.7. Routine immunization and wild polio eradication
 1.8. Expand community and facility Integrated Management of Mother
Newborn and Child Illnesses (IMNCI).
107

Cont’d
 1.9. EnhancedYouth Friendly services.
 1.10. Capacity building for program management of maternal and child
health services.
 1.11. Strength the health extension program.
 1.12. Develop special, locally contact-specific relevant and effective
maternal and child health intervention for pastoralist communities.
108

Cont’d
 Policies and Strategies
▪ The government of Ethiopia has adopted numerous laws, policies
and programs that advance women's social and reproductive
rights.
▪ The National Health Policy: Its main objective is “to give a
comprehensive and integrated primary health care in a
decentralized and equitable fashion”.
109

Cont’d
 The national health policy of Ethiopia was adopted in 1993 based on the
principles of
1) democratization and decentralization,
2) the primary health care approach, and
3) preventive, promotive, basic curative and rehabilitative services.
 This policy has been the umbrella for the development of Health Sector
Development Program (HSDP), other health and health related relevant
policies and strategies have also been developed.
110

Cont’d
 Health Delivery System
▪ In the five year period (2006 – 2010) (Ethiopian Fiscal Year (EFY) 1998 –
2002), the number of public sector health facilities rose dramatically.
▪ To ensure the delivery of essential health services throughout the
country, the health care system has been reorganized from a six first to a
four and recently to a three tiered system.
▪ The primary hospital, health center and health posts together form a
Primary Health Care Unit (PHCU). Level two is a general hospital to
serve 1-1.5 million people; and level three is a Specialized Hospital
covering a population of 3.5-5 million people.
111

Cont’d
 The Health Sector Development Program (HSDP)
▪ The 20 years health sector strategy of Ethiopia has 5 year rolling plan
known as the Health Sector Development Program (HSDP) which was
started by the first HSDP (1997/8 - 2001/02).
▪ The HSDPs are parts of the country’s poverty reduction plan, which is
called Plan for Accelerated and Sustainable Development and
Eradication of Poverty (PASDEP)
112

Cont’d
▪ Records from the experience of HSDP I - III showed encouraging
improvements both in the health service coverage as well as in the
utilization of services at all levels of the health care system of the
country.
113

Health Sector Transformation Plan (HSTP)
 HSTP-I (July 2015–June 2020)
 Reductions in maternal mortality (decreased 676 deaths per 100,000 live
births in 2011 to 401 in 2017).
 under-5 mortality and infant mortality per 1000 live births decreased from
123 and 77 in 2005 to 59 and 47, respectively, in 2019.
 However, over the years, there have been no significant reductions in
neonatal mortality (33 deaths per 1,000 live births in 2019).
114

Cont’d
 HSTP-II (July 2020–June 2025)
 HSTP-II has set ambitious targets to reduce the maternal mortality rate to
279 per 100,000 live births
 Reduce under-5 and neonatal mortalities to 44 and 21 per 1,000 live births,
respectively
 Increasing skilled delivery attendance to 76%
 Coverage of ANC 4 to 81%,
115

cont’d
 The Government of Ethiopia developed 14 strategic directions,
along with their major activities, to achieve the targets laid out in
HTSP-II
 Enhance provision of equitable and quality comprehensive health
service
 Improve health emergency and disaster risk management
 Ensure community engagement and ownership
 Improve access to pharmaceuticals and medical devices and their
rational and proper use
116

Cont’d
✓ Improve regulatory systems
✓ Improve human resource development and management
✓ Enhance informed decision-making and innovations
✓ Improve health financing
✓ Strengthen governance and leadership
✓ Improve health infrastructure
117

Cont’d
 Enhance digital health technology
 Improve traditional medicine
 Enhance health in all policies and strategies
 Enhance private engagement in the heath sector
118

Cont’d
 Five priority issues were identified as part of the transformation agenda
for HSTP-II:
 Quality and Equity
 Information revolution
 Motivated, competent, and compassionate health workforce
 Health financing
 Leadership
119

Gender and Reproductive Health

Learning objectives:-
 1.Identify the conceptual differences between sex and gender, and
develop a common understanding about how gender is
constructed, maintained, and reinforced
 2. Discuss gender roles and relations
 3. Analyze gender based inequalities and its consequences
 4. Discuss gender based violence related to RH

The Concept of Gender
▪ Gender refers to the economic, social and cultural attributes and
opportunities associated with being male or female in a
particular social setting at a particular point.
▪ It is the social construction of male and female roles
▪ Sex is the biological difference between males and females

Ambo university md Introduction to RH.pdf

Cont’d…
 Gender stereotypes
▪ Refer to beliefs that are so ingrained in our consciousness that
many of us think gender roles are natural and we do not question
them.
▪ Typically, men are seen as being responsible for productive
activities outside the home and women are responsible for
productive and reproductive activities within the home.
▪ Gender relations have changed over time, because they are
nurtured by factors that change over time

Cont’d…
 Characteristics of Gender
✓ Relational:-Women's and men's roles and responsibilities are socially
determined (socially constructed)
✓ Hierarchical:- Power relations (unequal power relationships due to the
greater importance and value to the characteristics and activities associated
with what is masculine)
✓ Changes:- Changes over time (potential for modification through
development interventions)
✓ Context specific:- Varies with ethnicity, class culture etc
✓ Institutional:- Systemic (a social system that is supported by values,
legislation, religion, etc.)

Cont’d…
 This sexual division of labor is learned and clearly understood by
all members of society.
 These roles are classified in the following way;-
❖ Productive Role: work done by both men and women (but
primarily by men), for pay in cash or in kind, for marketing and
home consumption
❖ Reproductive Role: Child bearing and rearing responsibilities
and domestic tasks done by women in the house to maintain and
sustain the family

Cont’d…
❖ Community Managing Role: voluntary activities undertaken
primarily by women at the community level, as an extension of
their reproductive role
❖ Community Politics Role: Primarily undertaken by men,
involving decision making
❖ In the area of sexuality and sexual behavior women are expected
to make themselves attractive to men, but be more passive,
guarding their virginity, never initiating sexual activity, and
taking care to protect themselves from the uncontrolled sexual
desires of men.

Cont’d…
 “Gender Bias ” refers to gender based prejudice; assumptions
expressed without a reason and are generally unfavorable.
 while ”gender discrimination” refers to any distinction, exclusion
or restriction made on the basis of socially constructed gender
roles and norms which prevents a person from enjoying full human
rights.

Cont’d…
 Gender Equality and Equity
 Gender equality refers to similar treatment of women and men in
laws and policies, and equal access to resources and services
within families, communities and society at large.
 Gender equality is balanced representation and participation of
women and men within policy and governance and a reallocation
of power and redistribution of resources from men to women.

Cont’d…
 Gender equity on the other hand refers to fairness and justice in
the distribution of benefits and responsibilities between women
and men.
 Gender inequalities are unnecessary,avoidable and unjust.
 Gender inequality results unbalanced patterns of health risk, use of
health services, and health outcomes between women and men.
 Equity does not mean an equal distribution of resources, but a
differential distribution that ensures each person’s needs are met.

Cont’d…
 Gender based inequality (imbalance) and its consequences
▪ Women and men have unequal access to and control over
resources;often to a disadvantage of women.
▪ Having greater access to and control over resources usually
makes men more powerful than women in any social group.
▪ This may be the power of physical force, of knowledge and skills,
of wealth and income, or the power to make decisions because
they are in a position of authority. Men often have extended their
decision-making power over to reproduction and sexual matters
as well.

 Th

ACCESS TO AND CONTROL
OVER
INTERNAL
RESOURC
ES
ECONOMIC
AND
SOCIAL
RESOURCES
POLITICAL
RESOURCE
S
INFORMATIO
N
/EDUCATION
TIME
POWER AND DECISION-
MAKING

Cont’d…
 Gender inequities in health are concentrated in three types of
imbalance:-
✓ Health risks,
✓ Health needs and
✓ Responsibility in health care
 Consequences of gender inequality can be reflected in various
areas. Higher rate of dropout or non-enrolment, lower educational
attainment and skills acquisition, poverty and poorer health status
are examples.

Areas of gender inequality in health
Opportunity to
enjoy health
Access to
health
Power in health
sector
Health risk
Health needs
Responsibility
in the health
sector

Cont’d…
 The global gender gap index examines the gap between men
and women in four fundamental categories:-
❑ Economic participation and opportunity
❑ Educational attainment
❑ Political empowerment; and
❑ Health and survival.

Quiz (10%)
 Define reproductive health?
 Define reproductive health care?
 Discuss criteria to select an indicator?
 Explain gender discrimination and stereotype?
 Discuss characteristics of Gender?
137

Safe Motherhood
 What is safe motherhood?
 Ensuring that all women receive the care they need to be safe and
healthy throughout pregnancy and childbirth.
 Why safe motherhood?

Why Safe Motherhood?
 Disparities
 99% of the maternal deaths take place in developing countries
 Greatest disparity between developed and less developed countries among
common basic health status indicators
 Benefits of maternal health to perinatal and child health and survival
 Maternal death is generally avoidable
 (MATERNAL MORTALITY A “NEGLECTED TRAGEDY”)

Why Safe Motherhood
 Safe Motherhood as a vital social and economic investment
 When a woman is sick or dies
 families lose her contribution to household management and provision of
care for children and other family members
 the economy loses her productive contribution to the work force
 communities lose a vital member whose unpaid labor is often central to
community life

Maternal Mortality
 Maternal death:
 The death of a woman while pregnant or
 within 42 days after termination of pregnancy,
 Irrespective of the site and duration of pregnancy,
 from any cause related to or aggravated by the pregnancy or its
management,
 but not from accidental or incidental causes.
142

Cont’d
 Maternal morbidity:
 Any deviation, subjective or objective, from a state of physiological or
psychological well being of women.
 Women’s lifetime risk of Death:
 the risk of an individual woman dying from pregnancy or childbirth during
her lifetime.
143

Cont’d
 MD is the TIP OF THE ICEBERG – For every maternal death 16 – 50
mothers suffer from morbidity due to the consequences of pregnancy
and child birth.
 ICD Late maternal death: the death of a woman from direct or
indirect obstetric causes more than 42 days but less than one year after
termination of pregnancy.
144

Cont’d
 Globally
 Every year, there are more than 210 million pregnancies,where
nearly
 75 million are either unwanted or unplanned
 Close to 600-9000/100,000maternal deaths each year (1 per min.)
 1 maternal death=30 maternal morbidities
145

Africa
 Each year in Africa, 30 million women become pregnant, and 18 million
give birth at home without skilled care
 Every year over 250,000 African women die because of complications
related to pregnancy and childbirth.
 Each day 700 women die of pregnancy-related causes.
 12 of the 13 with the highest MMR in the world are in SSA countries
among which the top list includes Ethiopia
 Pregnancy related complications, remains one of the major causes of
morbidity and mortality in SSA
146

Cont’d
 Causes of maternal death:
 Direct causes: are those that result from obstetric complications of the
pregnancy state from interventions, omissions, incorrect treatment or from
chain of events.
 Examples: Abortion, Ectopic pregnancy, pre-eclampsia, Eclampsia,
Obstructed labor, infection, etc.
 Seventy percent of maternal deaths are usually preventable.
A. Haemorrhage: Includes antepartum, postpartum, abortion, and ectopic
pregnancy.
147

Cont’d
B. Unsafe Abortion: It is claimed as the commonest cause of maternal death
in our country accounting for 20 –40% of deaths.
C. Hypertensive disorders of pregnancy: This includes pre-eclampsia,
eclampsia, etc.
 Preeclampsia and eclampsia account for 10- 12% of maternal deaths.
D. Obstructed Labor and uterine rupture: The prevalence of obstructed labor
is said to be 47 % in Ethiopia.
 It accounts for 9% of the total maternal death.
148

Cont’d
E. Infection: introduction and multiplication of microbes in the pelvic
organs and other systems affecting the mother and new-born.
 Includes infection of; uterus, tubes urinary systems, fetal infections.
Accounts about 10% of MD.
149

Cont’d
Indirect causes of maternal death: deaths resulting from pre-existing
disease or disease that developed during pregnancy which are
aggravated by the physiologic changes during pregnancy.
 Includes: Anemia (the commonest), heart disease, DM, HIV/AIDS, TB,
Malnutrition
150

Maternal Mortality in Context:The Three D’s (Delays)
 There are three phases during which delays can contribute to the death
of pregnant and postpartum women and their new-borns.
1. Delay in deciding to seek care
 Failure to recognize signs of complications
 Failure to perceive severity of illness
 Cost consideration
 Previous negative experience with the health system
 Transportation
151

Cont’d
2. Delay in reaching care
 Lengthy distance to a facility
 Conditions of roads
 Lack of available transportation
3. Delay in receiving appropriate care
 Uncaring attitudes of providers
 Shortages of supplies and basic equipment
 Non-availability of health personnel
 Poor skills of health providers
152

Cont’d
 Life threatening delays can happen at home, on the way to care, or at the
place of care.
 Therefore, plans and actions that can be implemented at each of these
points are mandatory.
 Birth preparedness and complication readiness to reduce delays
 Women-friendly care to enhance acceptability
153

Causes of Maternal Morbidity
 Maternal morbidity is difficult to measure due to variation in the definition and
criteria to diagnose.
 The risk factors for maternal morbidity include prolonged labor, haemorrhage,
infection, preeclampsia, etc.
 the commonest long term complication of pregnancy and child birth include:
A. Infection: There is high risk of infection of the genital organs (cervix, uterus,
tubes, ovaries and peritoneum) after prolonged labor, when delivery takes place
in unclean settings, retained parts of conception after unsafe abortion and
delivery.
154

Cont’d
B. Fistula: holes in the birth canal that allow leakage from the urethra,
bladder or rectum into the vagina.
 They present with continuous leakage of urine or feces or both.
 The commonest cause in our country is obstructed labor as opposed to
surgery and cancer in the developed world.
C. Incontinence: is leakage of urine upon straining or standing.
D. Infertility: Unable to be pregnant for a year despite unprotected
sexual intercourse.
155

Cont’d
E. Uterine prolapse: the falling or sliding of the uterus from its normal
position into the vaginal canal.
 Commonest predisposing factors include prolonged labor, heavy
exercise, multiple childbirths, etc.
F. Nerve Damage: As a result of prolonged labor, there may be
compression or damage of the nerves in the pelvis (Sciatic nerve).
G. Psychosocial problems: maternal blues aggravated by other
conditions
H. Others, Include, pain during intercourse, anemia, etc.
156

Risk factors for Maternal Health
Socio-cultural factors: early marriage, early childbirth, harmful
traditional practices including female genital mutilation, etc.
Economy: Socio economic status affects the women’s status by affecting
their decision making roles in the community, educational status, health
coverage, level of sexual abuse, etc.
Inadequate Health Service Coverage: Most mothers do not get care
during pregnancy and most deliveries are unattended.This is due to lack
of transportation, distance from health facilities, small number of health
facilities, etc.
157

Cont’d
Psychological factors: For instance, after sexual abuse women are at
great risk of depression.
Health and nutrition services: The health status of women who are not
getting adequate amount of nutrients and proper reproductive health
services could be affected.
Interaction with providers: Some health care providers are,
unsympathetic and uncaring as they do not respect women's cultural
preferences. E.g. privacy, birth position, or treatment by women providers.
Gender Discrimination: E.g. lack of women empowerment, giving more
attention to a male child.
158

Measures of maternal mortality
 There are three distinct measures of maternal mortality in widespread
use:
 The maternal mortality ratio
 The maternal mortality rate and
 The lifetime risk of maternal death.
 The most commonly used measure is the maternal mortality ratio
 The maternal mortality rate, that is, the number of maternal deaths in a
given period per 1000 women of reproductive age during the same time
period, reflects the frequency with which women are exposed to risk
through fertility
159

Cont’d
The lifetime risk of maternal death takes into account both the
probability of becoming pregnant and the probability of dying as a result
of that pregnancy cumulated across a woman’s reproductive years.
 In theory, the lifetime risk is a cohort measure, but it is usually calculated
with period measures for practical reasons.
 It can be approximated by multiplying the maternal mortality rate by the
length of the reproductive period (around 35 years).
 Thus, the lifetime risk is calculated as [1-(1-maternal mortality rate)
160

Cont’d
Why maternal mortality is difficult to measure?
 Maternal mortality is difficult to measure for both conceptual and
practical reasons.
 Maternal deaths are hard to identify precisely because this requires
information about deaths among women of reproductive age, pregnancy
status at or near the time of death, and the medical cause of death.
 All three components can be difficult to measure accurately, particularly
in settings where deaths are not comprehensively reported through the
vital registration system and where there is no medical certification of
cause of death.
161

Cont’d
 Moreover, even where overall levels of maternal mortality are high,
maternal deaths are nonetheless relatively rare events and thus, prone to
measurement error.
 As a result, all existing estimates of maternal mortality are subject to
greater or lesser degrees of uncertainty.
162

Cont’d
 Broadly speaking, countries fall into one of four categories:
 Those with complete civil registration and good cause of death
attribution – though even here, misclassification of maternal deaths can
arise, for example, if the pregnancy status of the woman was not known
or recorded, or the cause of death was wrongly ascribed to a non-
maternal cause.
 Those with relatively complete civil registration in terms of numbers of
births and deaths, but where cause of death is not adequately classified;
cause of death is routinely reported for only 78 countries or areas,
163

Cont’d
 Those with no reliable system of civil registration where maternal
deaths – like other vital events – go unrecorded.
 Currently, this is the case for most countries with high levels of maternal
mortality.
 Those with estimates of maternal mortality based on household
surveys, usually using the direct or indirect sisterhood methods.
 These estimates are not only imprecise as a result of sample size
considerations, but they are also based on a reference point some time
in the past, at a minimum six years prior to the survey and in some cases
164

Cont’d
 WHO, UNICEF and UNFPA have developed estimates of maternal
mortality primarily with the information needs of countries with no or
incomplete data on maternal mortality in mind, but also as a way of
adjusting for underreporting and misclassification in data for other
countries.
 A dual strategy is used that adjusts existing country information to
account for problems of underreporting and misclassification and uses a
simple statistical model to generate estimates for countries without
reliable data.
165

Cont’d
Approaches for measuring maternal mortality
 Commonly used approaches for obtaining data on levels of maternal
mortality vary considerably in terms of methodology, source of data and
precision of results.
 As a general rule, maternal deaths are identified by medical certification in
the vital registration approach, but generally on the basis of the time of death
definition relative to pregnancy in household surveys (including sisterhood
surveys), censuses and in Reproductive Age Mortality Studies (RAMOS).
166

Cont’d
Vital registration
 In developed countries, information about maternal mortality is derived
from the system of vital registration of deaths by cause.
 Even where coverage is complete and all deaths medically certified, in
the absence of active case-finding, maternal deaths are frequently
missed or misclassified.
 In many countries, periodic confidential enquiries or surveillance are
used to assess the extent of misclassification and underreporting.
167

Cont’d
Vital registration
 A review of the evidence shows that registered maternal deaths should
be adjusted upward by a factor of 50% on average.
 Few developing countries have a vital registration system of sufficient
coverage and quality to enable it to serve as the basis for the assessment
of levels and trends in cause-specific mortality including maternal
mortality.
168

Cont’d
Direct household survey methods
 Where vital registration data are not appropriate for the assessment of cause-
specific mortality, the use of household surveys provides an alternative.
 However, household surveys using direct estimation are expensive and
complex to implement since large sample sizes are needed to provide a
statistically reliable estimate.
 The most frequently quoted illustration of this problem is the household survey
in Addis Ababa, Ethiopia, where it was necessary to interview more than 32,300
households to identify 45 deaths and produce an estimated MMR of 480.
169

Cont’d
Indirect sisterhood method
 The sisterhood method is a survey-based measurement technique that in
high-fertility populations substantially reduces sample size
requirements since it obtains information by interviewing respondents
about the survival of all their adult sisters.
 Although sample size requirements may be reduced, the problem of
wide confidence intervals remains.
170

Cont’d
 Furthermore, the method provides a retrospective rather than a current
estimate, averaging experience over a lengthy time period (some 35 years,
with a midpoint around 12 years before the survey).
 For methodological reasons, the indirect method is not appropriate for use
in settings where fertility levels are low [total fertility rate (TFR)
171

Cont’d
Direct sisterhood method
 The Demographic and Health Surveys (DHS) use a variant of the sisterhood approach, the
“direct” sisterhood method.
 This relies on fewer assumptions than the original method, but it requires larger sample sizes
and the information generated is considerably more complex to collect and to analyze.
 The direct method does not provide a current estimate of maternal mortality, but the greater
specificity of the information permits the calculation of a ratio for a more recent period of time.
 Results are typically calculated for a reference period of seven years before the survey,
approximating a point estimate some three to four years before the survey.
172

Cont’d
 Because of relatively wide confidence intervals, the direct sisterhood
method cannot be used to monitor short-term changes in maternal mortality
or to assess the impact of safe motherhood programmes.
 The Demographic and Health Surveys have published an in-depth review of
the results of the DHS sisterhood studies (direct and indirect methods) and
have advised against the duplication of surveys at short time-intervals.
 WHO and UNICEF have issued guidance notes to potential users of
sisterhood methodologies, describing the circumstances in which it is or is
not appropriate to use the methods and explaining how to interpret the
results.
173

Cont’d
Reproductive Age Mortality Studies
 The Reproductive Age Mortality Study – RAMOS – involves identifying and
investigating the causes of all deaths of women of reproductive age.
 This method has been successfully applied in countries with good vital
registration systems to calculate the extent of misclassification and in
countries without vital registration of deaths.
 Successful studies in countries lacking complete vital registration use multiple
and varied sources of information to identify deaths of women of reproductive
age; no single source identifies all the deaths.
174

Cont’d
 Subsequently,interviews with household members and health-care providers and
reviews of facility records are used to classify the deaths as maternal or otherwise.
 Properly conducted,the RAMOS approach is considered to provide the most
complete estimation of maternal mortality,but can be complex and time consuming
to undertake,particularly on a large scale.
Verbal autopsy
 Where medical certification of cause of death is not available,some studies assign
cause of death using verbal autopsy techniques.
 However,the reliability and validity of verbal autopsy for assessing cause of death in
general and identifying maternal deaths in particular,has not been established
175

Cont’d
Census
 There is growing interest in the use of decennial censuses for the
generation of data on maternal mortality.
 A high-quality decennial census could include questions on deaths in
the household in a defined reference period (often one or two years),
followed by more detailed questions that would permit the
identification of maternal deaths on the basis of time of death relative
to pregnancy (verbal autopsy).
176

Summary of Causes of maternal death
177

When are child deaths occurring?
 The 10.6 million annual child deaths are not distributed
evenly over the 0-4 year age period
 More than 70% of all child deaths occur in the first year of
life

Neonatal health
 Two-thirds of neonatal deaths occur within the first
week
• Two-thirds of neonatal deaths in the first week occur
within 24 hours of life
• Major causes of neonatal deaths globally are:birth
asphyxia (23%), infections (36%),and preterm
complications (27%)
• Neonatal death contributes to 40% of under 5yr
mortality globally

Neonatal health
 Preterm and LBW babies are at higher risk of complications and
death
 Preterm babies are babies born before 37 weeks gestation, LBW
(low birth weight) babies born with a birth weight of fewer than
2500 grams
 Low birth weight is associated with 60-80% of neonatal deaths

Neonatal health
 Infections: in very high mortality settings almost 50% of
deaths are due to severe infections including neonatal
sepsis, pneumonia, diarrhea, and neonatal tetanus

Neonatal health
 Birth Asphyxia: When a baby doesn’t begin or sustain adequate
breathing at birth
 5-10% of all newborns need resuscitation at birth
 Nearly 1 million babies die each year because they don’t breathe
normally at birth

Progress has been variable
 Neonatal mortality has fallen at a lower rate than post-neonatal or early
child mortality
 Relatively greater progress has been made in some regions and
countries
e.g. neonatal mortality is now 58% lower in high-income countries than in 1983,
compared to a 14% reduction in low/middle-income countries
 Large variations in mortality rates exist even within the same country

Neonatal health
When do we need to worry?
➢Inadequate shelter,
➢low temperature
➢ Low exclusive breastfeeding practice
➢ No or limited access to neonatal health care
➢ No or limited attendance of deliveries by a skilled
attendant
➢ No or limited care in the first 24-48hrs after delivery
➢ High neonatal tetanus rate and/or low TT coverage
among women of reproductive age

Neonatal health
How do we plan a Prevention/response program
 Link neonatal health response with primary health care and
reproductive health care response plan.

Neonatal health
In the acute initial phase:
 Ensure essential neonatal care is incorporated in the Minimum
Initial Service Package for reproductive health
 Ensure that neonatal illness and death are included in
surveillance format at the community and facility level
 Promote immediate and exclusive breastfeeding, discourage
introduction or promotion of artificial feeding
 Distribute baby cloth (hat and warm clothing) in contexts where it
is needed (cold temperature)
 Include neonatal resuscitation kit in medical kit supplies

Neonatal health
After the acute initial phase:
 Depending on program direction, child health or reproductive
health include all the essential components of neonatal health care
addressing the three main causes of mortality
 Include neonatal illness and death data in population-based
surveys, monthly reporting formats

Neonatal health
How do we work with the community?
 Promote immediate and exclusive breastfeeding
 If needed organize ‘private breastfeeding corners or rooms’
 Promote kangaroo mother care (KMC) – for the care of n preterm/LBW
babies
 Promote clean delivery practice and attendance of births by skilled
attendants
 Awareness where the community can access neonatal, and maternal health
care
• Train community health workers and volunteers on newborn care, and care
in the first days of life

Adolescent and youth reproductive health
190

Definition
 World Health Organization defines adolescents as individuals between 10
and 19 years of age.
 The broader terms "youth" and “young” encompass the 15 to 24 year-old
and 10 to 24 year-old age groups, respectively.
191

Cont’d
Definitions:
 Period between childhood & adulthood
 Involves distinct physiological, psychological, cognitive, social &
economic changes.
1. Adolescent:10-19 years of age
2. Youth: 15-24 years of age
3. Young people:15- 29 years of age

Cont’d
 For girls, puberty is a process generally marked by the production of
estrogen, the growth of breasts, the appearance of pubic hair, the growth
of external genitals, and the start of menstruation.
 For boys, it is marked by the production of testosterone, the enlargement
of the testes and penis, a deepening of the voice, and a growth spurt.
193

Why focus on adolescent and young people?
I. Number/ proportion:
 Account to 60% of the population in Ethiopia (below 25 years of age)
II. Nature of adolescents and young on sexuality
 Major physical, cognitive, emotional, sexual and social changes occur
during adolescence and affects young people’s sexual behavior

Nature of adolescents and young on sexuality…
 Many young people engaged in risky behaviors due to
 Curiosity
 Peer pressure
 Sexual maturation
 A feeling of vulnerability
 A sense of omnipotence
 The increasing gap between puberty and marriage: Unmarried youth
require reproductive health care for a longer period

Why focus…?
III. Health and health related issues:
 Higher proportion of HIV and STI among adolescents and young
 Higher risk of maternal death between 15-19 year of age as compared to 25-29
years of age (4X)
 Many young women are sexually active and do not use contraceptive methods
1. Do not expect to have sex &
2. lack knowledge about contraceptive
 Adolescent births are more likely to result in LBW, premature birth, stillbirth &
Neonatal deaths.

Youth and diversity
– Different backgrounds
– Different stages of life
– Different individual needs

Barriers for young women
•Gender roles and stigma around youth sexuality
•Gender-based violence
•Child marriage
•Poor knowledge of abortion laws, services and technology
•Lack of youth-focused services
•Health providers attitudes

Adolescents today
 The current generation of young people is the healthiest, most educated,
and most urbanized in history.
 However, there still remain some serious concerns:
 Education:
 Sexuality
 Health
199

Characteristics of the adolescence period
 The period when the individual progresses from the point of initial
appearance of secondary sex characteristics to sexual maturity.
 It is period when psychological processes and patterns of identification to
those of an adult.
 Transition from the state of total socio-economic dependence to relative
independence.
200

Cont’d
 Period of rapid physiological changes and vulnerability to physical,
psychological and environmental influences.
 Period of physical, biological, psychological and social maturity from
childhood to adulthood.
201

Effects of social environment on adolescent RH behavior
Factors Positive influences Negative influences
Education Good health and sex education followed
by correct behavior
Early unwanted pregnancy, school
dropping, unemployment, prostitution,
drug abuse, crime, etc,
Media Spread information on healthy sexuality Pornography, smoking, crime (films,
papers, advertisement)
Entertainment Sports, in door games, educational films Crimes, drugs and alcohol abuse,
prostitution, early sexual activities
Family Integrated stable families are role models.
They can give appropriate information and
guidance on healthy life style
Abusive behaviour in families
Disintegrated families
Residence Healthy neighborhood "negative neighborhood" e.g.
prostitution areas
Health services Accessible information and services for
adolescents
Negative attitudes of health
professionals on adolescent sexuality
Religion Spiritual support Facilitation of the
adolescents in different activities
Prohibition of information on sexuality
202

Reproductive Health Risks and consequences for adolescents
 Adolescent reproductive health is affected by:
 pregnancy
 Abortion
 STIs
 sexual violence
 the systems that limit access to information and clinical services
 Nutrition
 psychological well-being
 Economic and gender inequities that can make it difficult to avoid forced,
coerced, or commercial sex.
203

Pregnancy
 In many parts of the world, women marry and begin childbearing during
their adolescent years.
 Pregnancy and childbirth carry greater risk of morbidity and mortality
for adolescents than for women in their 20s, especially where medical
care is scarce
 Girls younger than age 18 face two to five times the risk of maternal
mortality as women aged 18-25 due to prolonged and obstructed labor,
hemorrhage, and other factors
204

Cont’d
 Potentially life- threatening pregnancy-related illnesses such as
hypertension and anemia are more common among adolescent mothers,
especially where malnutrition is endemic.
 One in every 10 births worldwide and 1 in 6 births in developing
countries is to women aged 15-19 years.
205

Cont’d
 Unsafe abortion: About one in 10 abortions worldwide occurs among
women age 15-19
 Each year one million to 4.4 million adolescents in developing countries
undergo abortion
 Most of these procedures are performed under unsafe conditions due to:
 Lack of access to safe services.
 Self-induced methods
 Unskilled or non-medical providers
 Delay in seeking procedure
206

Abortion andYouth in Ethiopia
 Many young people are sexually active (age at first sexual
intercourse for women 16.6 years in 2016 )
• Contraception use among youth is very low
• 54% of pregnancies to girls under age 15 and 37% to ages 20-24 are
unwanted (MOH 2007:11 NAYRHS 2007-15)
• In 2008, 101 unintended pregnancies occurred per 1,000 women
aged 15–44 and 42% of all pregnancies were unintended (Singh et al
2010)

Cont’d
 STIs, including HIV/AIDS: The highest rates of infection for STIs,
including HIV, are found among young people aged 20 to 24; the next
highest rate occurs among adolescents aged 15 to 19
 Sexually transmitted infections can lead to life-long health problems,
including infertility.
 Worldwide, half of all sexually transmitted infections occur in
adolescents.
208

Cont’d
 Female Genital Cutting (FGC): FGC, the partial or complete removal of
external genitalia or other injuries to the female genitalia, is a deeply
rooted traditional practice that has severe reproductive health
consequences for girls.
 In addition to the psychological trauma at the time of the cutting, FGC
can lead to infection, hemorrhage, and shock. Uncontrolled bleeding or
infection can lead to death
209

Cont’d
 Commercial Sex: Sexual exposure is occurring at ages as young as 9-12
years as older men seek young girls as sexual partners to protect
themselves from STD/HIV infection.
 In some cultures, young men are expected to have their first sexual
encounter with a prostitute.
 Adolescents, especially young girls, often experience forced sexual
intercourse in sub– Saharan Africa, some girls’ first sexual experience is
with a sugar daddy, who provides clothing, school fees, and books in
exchange for sex.
210

Cont’d
 Sexual violence: Rape and involuntary prostitution can result in physical
trauma, unintended pregnancy, STIs, psychological trauma and increased
likelihood of high risk sexual behavior
211

RH indicators on adolescent and youth in Ethiopia
EDHS 2000, 2005, 2011 & 2016

Trends in use of contraception
7
5
2 2
14
13
3
9
29
27
2
22
33.9 33.4
2
22.8
0
5
10
15
20
25
30
35
40
Any Method Any Modern Method Pill Injectables
Percent of sexually experienced women age 15-24 who are using
contraception
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS
213

Trends in family planning knowledge
82
87
90
95
97 99
98.1 97.9
0
20
40
60
80
100
120
Women Men
Percentage who know about modern contraception, among women and
men aged 15-24, who had sex in the last 30 days
214

Trends on family planning knowledge
39
57 58
51.08
0
10
20
30
40
50
60
70
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHSA
Percent of women age 15-24 who heard
or saw a FP message on radio,TV, in
print medias or community events
40
51
65
43
0
10
20
30
40
50
60
70
Percent of men age 15-24 who heard or
saw a FP message on radio,TV, in print
medias or community events
215

Trends in unmet need for family planning
216
31
28
23
14.6
7
9
2
2.5
0
5
10
15
20
25
30
35
40
Percent of currently married women aged 15-24 with unmet need for FP
Spacing Limiting

Trends of age specific fertility rate
0
50
100
150
200
250
300
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Births per 1000 women
218

Reasons youth fail to receive RH care service
 Poor treatment
 Fear of being judged by service provider
 Lack of privacy and confidentiality
 Feeling that services are intended for married people
 Unaware of service locations or services offered
 Service fee (no/low pocket money at hand)

Youth Friendly Health services
Definition: WHO describes as
“Services that are :
 Accessible
 Safe
 Effective
 Acceptable and
 Appropriate for adolescents in meeting their need, in the right
place, and at the right price (free where necessary)”

Approaches for working with youth directly
1. Motivation-Stimulating behavior changes in individuals by marketing
a product, service or action
2. Health Education in reproductive health issues
3. Counseling
4. RH services-Such as STI screening & treatment, FP, pregnancy care…

Characteristics of youth friendly service
Programmatic characteristics
 Youth are involved in program design
 Both boys & girls are welcomed and served.
 Unmarried clients are welcomed & served
 Group discussions are available
 Parental involvement is encouraged but not required
 Affordable fees are available
 Drop-in clients are welcomed

Services intended to be provided as a package inYFS
1. Information and Counseling on SRH issues, and sexuality.
2. Promotion of healthy sexual behaviors through various methods including peer
education
3. FP information, counseling and methods including emergency contraceptive
methods
4. Testing Services: Pregnancy, HCT.
5. Prevention and Management of STIs
6. ANC, Delivery Services, PNC and PMTCT
7. Abortion and Post Abortion Care
8. Appropriate referral linkage between facilities at different levels

Service provider characteristics
 Staff are trained about adolescent issues
 Respect is shown to young people
 Privacy & confidentiality maintained
 Adequate time is given for client-provider interaction
 Peer counselors are available

Health facility characteristics
 Convenient hours
 Convenient location
 Adequate space
 Sufficient privacy
 Comfortable surroundings

Definition of terms
➢What is HIV?
➢What is AIDS ?
➢What is PMTCT ?
2/21/2023
228

Definition
➢ HIV stands for Human Immunodeficiency Virus which primarily attacks
the immune system.
➢ HIV is from a special family of viruses known as retroviruses.
➢ AIDS stands for Acquired Immune Deficiency Syndrome.
➢ Patients who are infected with HIV will develop signs and symptoms as
a result of immune depression which is collectively called AIDS.
➢ PMTCT stands for prevention of mother-to-child transmission
2/21/2023
229

HIV/AIDS Epidemiology
➢According to UNAIDS 2020 report, by the end of 2019, 75.7 million
people globally were infected with HIV since the start of the
pandemic in 1981,
➢With nearly 33 million total deaths.
➢There were 38.0 million people living with HIV in 2019 and 1.7
million people became newly infected in the same year.
➢The global cumulative increase in people living with HIV (PLHIV)
is mainly due to improved access to ART (increased survival),
alongside declining new HIV infections (though it is still very
2/21/2023
230

HIV/AIDS Epidemiology cont.….
➢Despite global efforts to eliminate mother-to-child transmission of
HIV, 15% of pregnant women living with HIV did not have access to
antiretroviral drugs to prevent transmission of HIV to their children
in 2019.
➢Unless these pregnant women are put on ART and viral suppression
(<50 copies/ml after 3-6 months on ART) is achieved, the chance of
MTCT will be high.
➢There are 1.8 million children 0-14 years living with HIV in 2019.
2/21/2023
231

➢The national adult (15-49 years) prevalence of HIV in 2019 in
Ethiopia was 0.9%, with the highest prevalence being in females
(1.2%).
➢Estimated number of PLHIV is 670,000; 44,000 are children less than
15 years of age.
➢Currently, there is a mixed type of distribution with wide regional
variations and high concentration in urban hot spot areas. 2/21/2023
232

➢There are several subpopulations with HIV prevalence exceeding
5% in urban areas.
➢Differences have been also observed in the prevalence among
regions and city administrations.
➢Gambella has the highest adult HIV prevalence (4.32%) followed by
Addis Ababa (3.58%), while Somali (0.16%) and SNNP (0.42%)
regions have the lowest prevalence.
2/21/2023
233

➢According to national estimates, HIV prevalence has declined
from 7.9% in 2004 to 2.9% in 2018 in urban areas of Ethiopia.
➢However, the data on rural areas, has shown no significant decline
but rather stabilized.
➢For instance, the prevalence in rural areas was 1% in 2004 and
stabilized at 0.4% from 2012 to 2018.
➢According to EDHS 2016, the current HIV prevalence is seven
times higher in urban areas than in rural areas (2.9% versus 0.4%,
respectively). 2/21/2023
234

➢ Although the prevalence of HIV among the pregnant population showed a
declining trend, parallel to that of the general population, the prevalence
was still higher amongst pregnant women.
➢ According to UNAIDS data in 2019 estimation, 5.4% of pregnant women
were HIV positive.
➢ Nationally, in 2019, there were a total of 19,110 HIV-positive pregnant
women.
➢ Of which, only 14,149 (74%) women were accessing PMTCT interventions,
➢ which is far below the global achievement of more than 85%. 2/21/2023
235

Modes of HIV transmission:
➢Unprotected sexual practice (anal, vaginal, oral) with an infected
person
➢Transfusion with infected blood or blood products
➢The use of needles, syringes, and cutting or perforating objects
contaminated by HIV-infected blood.
➢Sharing contaminated sharp for certain traditional practices; tooth
extraction, uvulectomy, female genital mutilation, circumcision, and
tattooing.
➢MTCT during pregnancy, labor and delivery, and breastfeeding
from infected women
➢Organ transplant from an infected donor
2/21/2023
236

MTCT
 MTCT can occur during pregnancy, childbirth, or through
breastfeeding
 As a mode of transmission, MTCT accounts for more than 10% of all
new HIV infections globally.
 Over 90% of new infections in infants and young children occur
through MTCT
 In the absence of interventions, the risk of MTCT is 20-45%, with the
highest rates in populations with prolonged breastfeeding
2/21/2023
237

MTCT Cont.….
▪ The risk of MTCT can be reduced to less than 2% with a package of
evidence-based interventions
▪ PMTCT minimizes the vertical transmission of HIV during
pregnancy, labor, and breastfeeding.
▪ PMTCT saved 1.4 million HIV-exposed children from HIV infection
b/n 2010 to 2018(UNAIDS, 2019)
2/21/2023
238

MTCT Cont.….
▪ HIV/AIDS prevalence decreased by 25% again from 2010 to 2018
years
▪ SDG 2015 to 2030 planned on goal 3.3 to just eliminate AIDS
epidemics in 2030
2/21/2023
239

TIMING OF MOTHER-TO-CHILD TRANSMISSION OF HIV
2/21/2023
240
During labor and delivery (10-
20%)
During
breastfeeding
(5-20%)

Risk factors for MTCT OF HIV
A. Viral factors
 Viral load
 Viral resistance
B. Maternal
 Maternal immunological status
 Maternal nutritional status
 Maternal clinical status
 Behavioral factors
 Antiretroviral treatment 2/21/2023
241

Risk factors for MTCT OF HIV Cont.…
C. Obstetrical
 Prolonged rupture of membrane
 Mode of delivery
 Intrapartum hemorrhage
 Obstetrical procedures
 Invasive fetal monitoring
D. Fetal and neonatal
Prematurity
Multiple pregnancies
Breastfeeding
Gastrointestinal tract
factors
Immature immune system
2/21/2023
242

1. Primary prevention
 Communication for behavior change (ABC HIV infection approach) to protect
reproductive-age men and women from becoming infected with HIV and
other STIs
 Provide voluntary counseling and testing services following the National HIV
Counseling and Testing Guidelines
 Promote correct and consistent use of condoms
 Encourage open discussion on reproductive health issues between parents
and their children
 Early diagnosis and treatment of STIs
2/21/2023
244

2. Prevention of unintended pregnancy Among HIV positive women
 Provide family planning counseling and service integrated into all
potential PMTCT and VCT service sites
 Provide health education about the use of dual family planning
service
 Ask and counsel women about any drug they are using
2/21/2023
245

3. Prevention of HIV transmission from infected women to their infants
 Ensure availability of antiretroviral drugs and other appropriate supplies for
PMTCT
 Provide testing and counseling services integrated with ANC, labor &
delivery, and postnatal care using an opt-out approach.
 Safer obstetrical practices
 Provide appropriate counseling on infant feeding and support exclusive
breastfeeding
2/21/2023
246

4. Treatment, care, and support for HIV-infected women ,
their infants and family
 Provide ART for all pregnant women
 Ensure appropriate follow-up of infants born to HIV-positive women
including OI prophylaxis and early infant diagnosis(DBS) at 6 weeks of age.
 Provide HIV testing for family
 Link PMTCT with care and support initiatives organized for infants and HIV-
infected women
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247

Care and treatment for HIV Positive pregnant, Laboring, and
lactating women
✓Testing and Counseling using an opt-out approach
✓WHO Clinical Staging
✓Screening for Opportunistic infections(OIs)
✓Management of OIs
✓Initiating ART at ANC
✓Adherence Preparation, Monitoring, and Support
✓Nutritional and social support
2/21/2023
248

Testing and Counseling
➢ All women with unknown HIV status coming for MCH services
should have their HIV status determined
➢Encourage pregnant/lactating women to attend HCF with their
partners and ensure that children of HIV-positive mothers are tested
➢Remind pregnant women during pre-test sessions ( individual or
group) that they can decline HIV testing without any subsequent
consequence
2/21/2023
249

Testing and Counseling Conti…
 Result of HIV testing should always be offered in a confidential
setting
 Effective post-test counseling of patients testing positive is essential
to assure their participation in full PMTCT services
2/21/2023
250

Testing and Counseling Cont…
❑Prioritize immediate information to be delivered
 Information on a positive result, medical help available, disclosure,
and risk reduction can be provided on the first day and others
gradually
 Therefore what counseling is immediately required is based on the
gestational age or stage of labor the need and the level of
understanding of your client
2/21/2023
251

WHO Clinical Staging
HIV-associated conditions are grouped into 4 WHO clinical stages that correlate with disease
progression and the likelihood of survival
Stage 1: Asymptomatic
Stage 2: Mild
Stage 3: Moderate
Stage 4: Severe
• It should be part of the baseline assessment (first visit) on entry into a care and treatment program
• Used to guide decisions on when to start co-trimoxazole prophylaxis and monitoring patient
response (if CD4 is not available)
• Following initiation of ART, staging on therapy (T-staging), using the same clinical parameters,
should be performed regularly as a means of monitoring ARV treatment success or failure.
2/21/2023
252

Screening for Opportunistic infections OIs
❖Before initiating ART and at every subsequent visit provider must
screen for possible opportunistic infection through:
✓A proper focused history by asking actively for symptoms
✓A standard physical exam
✓Use of laboratory tests
2/21/2023
253

Care and treatment……
➢ Giving preventive service that includes:
▪ Early intervention to prevent OIs and other HIV-related risk behavior
▪ Co-trimoxazole preventive therapy for both mother and infant
▪ INH preventive therapy for preventing Tuberculosis
▪ ITN to prevent malaria
2/21/2023
254

Cotrimoxazole Preventive Therapy (CPT)
❑ Give CPT to mother :
✓Any WHO clinical stage and CD4< 350 cells per mm3 OR
✓WHO clinical stage 3 or 4 irrespective of CD4 level
✓And if CD4 count is not available give CPT at WHO clinical stages 2,3 and
4
2/21/2023
255

Introduction to ARVs
 What is ART?
 ART stands for Anti-Retroviral Therapy; the treatment of HIV-infected
individuals with antiretroviral drugs.
 What is HAART?
 H-Highly, A-Active, A-anti, R-retroviral,T-Therapy
 It is the use of three or more antiretroviral drugs for the treatment of HIV
infection.
2/21/2023
256

The goal of ART
 To suppress the replication and reduce the number of viruses in the blood
 Increase the number of CD4 as much as possible and finally improve the
general health of the client.
 Antiretroviral therapy suppresses the viral replication to a below detectable
level,
 However the virus can never be eradicated completely from the body;
 hence the person should take the drugs lifelong, even if the symptoms have
disappeared.
 Since the virus cannot be eradicated, safer sex using a condom should be
practiced.
2/21/2023
257

ARV Drugs for Pregnant Women
There are four major classes of ARV drugs available for use in
Ethiopia:
1. The NRTI: This stands for 'Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors'
2. The NNRTI: This stands for 'Non-Nucleoside Reverse
Transcriptase Inhibitors.
3. INSTIs: Integrase strand transfer Inhibitors
4. The PI:This stands for Protease Inhibitor.
2/21/2023
258

Site of actions for NRTI, NNRTI, and PI
2/21/2023
259

Advantages of Combination therapy.
➢It takes three drugs to have sustained viral suppression (low level of
virus in the body).
➢Antiretroviral drugs from different drug groups attack the virus in
different ways.
➢Combinations of anti-HIV drugs may overcome or delay resistance.
2/21/2023
260

ART for pregnant women
➢ ART will improve the health of the woman and is the most effective intervention
in decreasing the risk of transmission of HIV to the infant.
➢ HIV-positive status is the only requirement for starting pregnant or lactating
women on ART
➢ All HIV-positive pregnant women should be started on ART as soon as possible
irrespective of gestational age, clinical stage, and CD4 count.
➢ HAART for HIV-positive pregnant is indicated based on the WHO programmatic
update issued in April 2012, Option B+ (test-and-treat principle).
➢ Once started, a woman should continue taking ART for her entire life.
2/21/2023
261

CONT…
▪ Since treatment is anticipated to be lifelong, make sure your client understands the
importance of adherence.
▪ Pregnant and post-partum women need adherence support—make use of Mother
Support Group
▪ ARVs side effects, drug-drug interaction, and need for adherence should discuss
before initiation
2/21/2023
262

CONT….
o If pregnant or lactating, a woman should start ART within 7 days
o A laboring mother should be initiated on ART immediately, accompanied by
strong adherence counseling and close follow up
2/21/2023
263

Option B+
✓Requires just one pill taken once daily
✓No need for CD4 test to initiate ART
✓Makes breastfeeding safer
✓Mothers start treatment early, so the quality of life and survival
are better 2/21/2023
264

Benefits of Option B+
✓ Requires just one pill taken once daily
✓ No need for CD4 test to initiate ART
✓ Makes breastfeeding safer
✓ Mothers start treatment early, so the quality of life and survival are better
2/21/2023
265

Benefits of Option B+ CONT…
✓ Maintains continuity of care: ANC to post-weaning so improves infant testing
as well as post-partum uptake of FP services
✓ Minimize HIV transmission among a discordant partnership
✓ Ongoing treatment of the mother will protect future pregnancies from the start
of conception.
2/21/2023
266

Challenges of Benefits of Option B+
✓ Treatment is intended to be lifelong
✓ Adherence is also very important to prevent the occurrence of treatment
failure
✓ Poor adherence may cause treatment failure
✓ Side effects of drugs need to be monitored
2/21/2023
267

Recommended Option B+ ARV drugs regimen in PMTCT
Scenario:-Diagnosis of HIV and initiation of
ART at:
Type of regimen for the
woman
ANC (newly identified ) TDF+3TC+ DTG
Intra-partum (L&D), newly identified TDF+3TC+DTG
Postpartum period(newly identified ) TDF+3TC+DTG
Pregnant mother on Pre-ART follow up TDF+3TC+DTG
Already on HAART before pregnancy Continue with the regimen
the woman has started
2/21/2023
268

Summary of sequencing for preferred first, second and third-
line Option B+ ART regimens in pregnant women
Population Preferred First
line
Regimens (PFR)
Alternative First
line
Regimens (AFR)
Special
circumstanc
es c
(SC)
Women & adolescent
girls who have desire
for pregnancy or are
pregnant (including
those with TB/HIV
coinfection) b
TDF + 3TC + DTG
(FDC)
TDF + 3TC +
EFV*
AZT + 3TC +
EFV*
AZT + 3TC + DTG
TDF+3TC+
ATV/r**
AZT+3TC +
ATV/r**
2/21/2023
269

Adherence advice
 Providing basic information on HIV and its manifestations
 Clearly stating benefits and side effects of drugs
 Identifying when a client should seek urgent help
 Explaining how medications should be taken
 Stressing the importance of not missing any doses
2/21/2023
270

Monitoring of women initiated on option B+
o All HIV-infected individuals require a standard clinical assessment at
every visit
o At each visit HCW should be checked for:
✓ HIV-related diseases including TB screening questions
✓ Change in WHO stage; any finding suggesting ART Tx Failure
✓ Drug side effects (ARV, CTX, INH, Anti-TB drugs)
✓ Adherence 2/21/2023
271

Monitoring and managing Drug-Drug interaction
o Effect of drugs can be modified by the use of another
o HIV-positive women may be under treatment for other conditions besides HIV
o Thus it is important that you know what interactions exist between the group of
drugs that you use to provide effective treatment for your clients
o Most of the drugs are metabolized by kidney and liver
o Eg:TDF/3TC is metabolized by the kidney
EVF/DTG by the liver
2/21/2023
272

Drug-Drug Interaction
❖ Rifampicin induces metabolism of NNRTIs;
NVP and EFV
❖Anticonvulsants:induce PIs and NNRTIs
❖NVP/EFV induces metabolism of estrogen containing oral
contraceptive
❖EFV may reduce effect of systemic ketoconazole
2/21/2023
273

Treatment failure
❖Treatment failure is diagnosed when:
o New opportunistic infections
o Clinical stage 3 and 4 after 6month treatment
o CD4 count less than 250cells/mm3 or
o Persistent CD4 level less than 100 cells/mm3
2/21/2023
274

Predisposing factors for treatment failure
o Drug resistance
o Poor treatment adherence
o Medications poorly absorbed
o Other illness or conditions
o Poor health before starting treatment
o Side effect of drugs or drug-drug interactions
o Substance abuse
2/21/2023
275

Nutritional Care and Support for HIV Infected
Pregnant/Lactating Women
 Nutrient requirements for an HIV infected pregnant or lactating
women are TWICE that of a non-pregnant, non-lactating woman!
1. Should fight effects of HIV infection and associated OIs
2.Should support optimum fetal growth and development/ as well
as lactation.
2/21/2023
276

Nutrient cont.…..
✓ However nutrient intake and use can be reduced in HIV infected pregnant and
lactating women due to:
 Loss of appetite (infection, depression, side effects of drugs)
 Reduced absorption (chronic diarrhea, and HIV related intestinal cell damage)
 Impaired utilization and storage of nutrients
2/21/2023
277

PMTCT during Labor and delivery
✓ Use a Partograph to allow early detection and management of prolonged
labor
✓ Artificial rupture of membrane(ARM) increases risk of HIV transmission
✓ Do not perform routine episiotomy
✓ Avoid frequent vaginal examination
✓ Do not milk the umbilical cord before cutting
2/21/2023
278

Newborn and Postnatal care
✓ Do not suction with nasogastric tube unless there is meconium-stained liquor
✓ Immediately after birth, wipe the baby dry with a towel to remove maternal body fluids
✓ Give BCG and polio vaccine after birth to all babies born to HIV infected mothers (as
for all infants)
✓ Provide NVP and AZT prophylaxis for the duration of 6 weeks then NVP for the next 6-12
weeks irrespective of the feeding status
✓ HIV test for exposed infant at 6wk (DBS test)
2/21/2023
279

ART prophylaxis for HEI
o AZT and NVP for 6wks then NVP for 6-12 wks
o DNA-PCR must be tested at 6wk
o Newly diagnosed breast feeding mother: high risk exposed infant
so:
➢DNA-PCR first done then put on ART if positive
➢If negative start AZT and NVP and NVP for 12wks
2/21/2023
280

Reference
➢ National Comprehensive PMTCT/MNCH manual 2021
➢ World Health Organization (2016). 'Mother-to-child transmission of HIV.
➢ UNAIDS (2017) ‘Start Free Stay Free AIDS Free: 2017 progress report
➢ UNAIDS Data(2019).
➢ UNAIDS(2021). Global HIV &AIDS statistic fact sheet
➢ EMOH(2018). National consolidated guidelines for comprehensive HIV
prevention ,care and treatment
➢ Le Saout E(2020).PMTCT of HIV. International MSF working group
2/21/2023
281

Sexually Transmitted Infections and Reproductive Tract
Infections

283
Learning Objectives
 Describe RTIs and STIs
 Explain the public health significance of STIs
 Describe the main STI pathogens
 Describe risk factors for STIs
 Describe STIs control strategies
 Describe the challenges to STIs control

284
I. Definition of Terms
 Reproductive tract infections (RTIs) are infections of the genital tract
of women and men.
 There are three types of RTIs:
1. Sexually transmitted infections (STIs)
 Infections caused by organisms that are passed through sexual activity
with an infected partner.
 More than 40 have been identified, including chlamydia, gonorrhea,
hepatitis B and C, herpes, human papillomavirus, syphilis,
trichomoniasis, and HIV.

285
Definition…
2. Endogenous infections
 Infections that result from an overgrowth of organisms normally present in
the vagina.
 These infections are not usually sexually transmitted and include bacterial
vaginosis and candidiasis.
3. Iatrogenic infections
 Infections introduced into the reproductive tract by a medical procedure
such as menstrual regulation, induced abortion, IUD insertion, or
childbirth.
 This can happen if surgical instruments used in the procedure are not
properly sterilized, or if an infection already present in the lower
reproductive tract is pushed through the cervix into the upper
reproductive tract.

286
Definition…
 These three types of RTIs overlap and should be considered
together.
 For example,some STIs, like gonorrhea or chlamydia, can be spread
in the reproductive tract if not treated prior to a procedure.
 In addition, some non-sexual infections, such as candidiasis, can be
passed on through sexual activity.
 Not all STIs are RTIs; and not all RTIs are sexually transmitted; STI
refers to the way of transmission whereas RTI refers to the site where
the infections develop.

287
Sites of Infection: Female Anatomy
Fallopian tubes
Vulval, labial, vagina
Genital ulcers
(syphilis,chancroid,herpes),
genitalwarts
Vagina
Bacterial
vaginosis,
yeast infection,
trichomonas
Uterus
Gonorrhoea,
Chlamydia,
vaginal
bacter
Cervix
Gonorrhoea, chlamydia
herpes

288
Sites of Infection: Male Anatomy
Penis, Scrotum
Genital ulcers (Syphilis,
chancroid, herpes)
Genital warts
Spermatic
cord
Epididymis
Urethra
Gonorrhea,
chlamydia
Testes

289
II. Public Health Significance of STIs
 Over 340 million curable, and much more incurable, STIs occur each year.
Among women, non-sexually transmitted RTIs are usually even more
common.
 In developing countries, STIs and their complications rank in the top five
disease categories for which adults seek health care.
 In women (15-49 years), STIs, even excluding HIV, are second only to
maternal factors as causes of disease, death, and healthy life lost.

290
Public Health…
 Self-reported prevalence of STIs in Ethiopia 2 % (women) and 1.5 %
(men)
 The links between STIs and HIV
 The presence of an untreated STI enhances both the acquisition and
transmission of HIV
 STI treatment is an important HIV prevention strategy in a general population
 Integration of HIV/AIDS programs with STIs prevention and care programs is
economically advantageous (similar interventions and target audiences)

291
Public Health…
 Clinical services offering STI care are important for providing information and education
about STIs including HIV in order to promote lower-risk behavior.
 STIs can lead to the development of serious complications.
 Women: cervical cancer, pelvic inflammatory disease, chronic pelvic pain, ectopic
pregnancy, and infertility.
 Men: sub-fertility
 Newborn: blindness and lung damage
 Syphilis can result in congenital syphilis for the baby and fatal cardiac, neurological, and
other complications in adults
 Genital warts can lead to genito-anal cancers

292
Public Health…
 Untreated gonococcal and chlamydial infections in women will result in
pelvic inflammatory disease in up to 40% of cases. One in four of these
will result in infertility.
 In pregnancy, untreated early syphilis will result in a stillbirth rate of
25% and be responsible for 14% of neonatal deaths – an overall
perinatal mortality of about 40%. Syphilis prevalence in pregnant
women in Africa, for example, ranges from 4% to 15%.

293
Public Health…
 Human papillomavirus (HPV) causes about 500 000 cases of cervical
cancer annually with 240,000 deaths, mainly in resource-poor countries.
 Worldwide, up to 4000 newborn babies become blind every year
because of eye infections attributable to untreated maternal gonococcal
and chlamydial infections.

294
Public Health…
 STIs constitute a huge health and economic burden, especially for
developing countries, where they account for 17 % of economic
losses due to ill-health
 Herpes simplex virus type 2 (HSV-2) infection is the leading cause of
genital ulcer disease (GUD) in developing countries. Data from sub-
Saharan Africa show that 30%–80% of women and 10%–50% of men
are infected.
 Throughout the world,HSV-2 seropositivity is uniformly higher in
women than in men and increases with age.

295
Public Health…
 HSV-2 plays an important role in the transmission of HIV infection. A
study in Mwanza, the United Republic of Tanzania, showed that 74%
of HIV infections in men and 22% in women could be attributable to
HSV-2
 Hepatitis B virus (HBV), which may be transmitted sexually results
in an estimated 350 million cases of chronic hepatitis and at least
one million deaths each year from liver cirrhosis and liver cancer.
 A vaccine to prevent hepatitis B infection, and thereby reduce the
incidence of liver cancer, exists

296
Public Health…
 The socioeconomic costs of STIs and their complications are substantial
 Ranks among the top 10 reasons for healthcare visits in most developing
countries, and substantially drain both national health budgets and household
income.
 Care for the sequel of STIs accounts for a large proportion of tertiary
healthcare costs
 The social costs of STIs include conflict between sexual partners and domestic
violence.

297
III. Main STI Pathogens
 More than 30 pathogens are transmissible through sexual intercourse-
oral, anal, or vaginal.
 The main sexually transmitted bacteria are:
 Neisseria gonorrhoeae (causes gonorrhea)
 Chlamydia trachomatis (chlamydial infections)
 Treponema pallidum (causes syphilis)
 Haemophilus ducreyi (causes chancroid)
 Klebsiella granulomatis (causes granuloma inguinale or donovanosis)

298
STI Pathogens…
 The main sexually transmitted viruses are:
 Human immunodeficiency virus (causes AIDS)
 Herpes simplex virus (causes genital herpes)
 Human papillomavirus (causes genital warts)
 Hepatitis B virus
 Cytomegalovirus
 The main parasitic organisms are:
 Trichomonas vaginalis (causes vaginal trichomoniasis)
 Candida albicans (causes vulvovaginitis in women; inflammation of the
glans penis and foreskin [balano-posthitis] in men).

299
IV. Risk Factors for STIs
 Biological factors
 Behavioral factors
 Social factors

300
V.Why Invest in STI Prevention and Control Now?
 To reduce STI-related morbidity and mortality
 To prevent HIV infection
 Genital ulcer diseases have been estimated to increase the risk of
transmission of HIV 50–300-fold per episode of unprotected sexual
intercourse
 Improved syndromic management of STIs reduced HIV incidence by 38% in
a community intervention trial in Mwanza
 Thailand also reduced HIV prevalence by effectively controlling STIs

301
Why Invest…
 To prevent serious complications in women
 STIs are the main preventable cause of infertility
 PID, ectopic pregnancy, and cervical cancer
 To prevent adverse pregnancy outcome
 Perintatal deaths
 Spontaneous abortions
 Preterm deliveries
 Ophthalmia neonatorum

302
Why invest…
 Universal institution of an effective intervention to prevent congenital
syphilis should prevent an estimated 492 000 stillbirths and perinatal
deaths per year in Africa alone.
 In terms of cost–effectiveness, in Mwanza, with a prevalence of active
syphilis of 8% in pregnant women, the cost of the intervention is estimated
to be US$ 1.44 per woman screened, US$ 20 per woman treated, and US$
10.56 per disability-adjusted life year (DALY) saved.
 The cost per DALY saved from all syphilis-screening studies ranges from
US$ 4 to US$ 19

303
VI. STI Control Strategies
1. Prevention by promoting safer sexual behaviors;
2. General access to quality condoms at affordable prices;
3. Promotion of early recourse to health services by people suffering
from STIs and by their partners;
4. Inclusion of STI treatment in basic health services;
5. Specific services for populations with frequent or unplanned high-

304
Control Strategies…
6. Proper treatment of STIs, i.e. use of correct and effective medicines; treatment
of sexual partners; education and advice; reliable supply of condoms;
7. Screening of clinically asymptomatic patients;
8. Provision for counseling and voluntary testing for HIV infection;
9. Prevention and care of congenital syphilis and neonatal conjunctivitis;
10. Involvement of all relevant stakeholders, including the private sector and the
community, in the prevention of STIs and prompt contact with health services
for those requiring care.

305
The Role of Clinical Services in Reducing the Burden of STIs/RTIs
People with STI/RTI
Symptomatic
Seek care
Accurate diagnosis
Correct treatment
Completed treatment
Cure

306
In order to address these challenges,health providers should:
 Raise awareness in the community about STIs/RTIs and how they can be
prevented
 Promote early use of clinic services.
 Promote safer sexual practices when counseling clients.
 Detect infections that are not obvious.
 Prevent iatrogenic infection
 Manage symptomatic STI/RTI effectively
 Counsel patients on staying uninfected after treatment.

307
Traditional Approaches to STI Diagnosis
1. Etiologic diagnosis: using laboratory tests to identify the causative agent
2. Clinical diagnosis: using clinical experience to identify the symptoms
typical for a specific STI.
 Even in a well-structured health system, etiological and clinical diagnoses
are problematic.
 Etiological diagnosis is expensive and time-consuming; it requires
special resources and delays treatment.
 With a clinical diagnosis, it is easy to diagnose some STIs incorrectly and
also to miss mixed infections.

308
The STI Syndromes and the Syndromic Approach to Case Management
 Many different agents cause STIs.
 However some of these agents give rise to similar or overlapping clinical manifestations.
 The main STI syndromes are:
@ Urethral discharge
@ Genital ulcer
@ Inguinal bubo
@ Scrotal swelling
@ Vaginal discharge
@ Lower abdominal pain
@ Neonatal conjunctivitis

309
Main Features of Syndromic Management
 Periodic laboratory-based classification of the main causal pathogens by
the clinical syndromes they produce
 Use of flow charts derived from this classification to manage a particular
syndrome
 Treatment for all important causes of the syndrome
 Notification and treatment of sex partners.

310
Obstacles to the Provision of Services for STI Control
 Decline in interest and resources for STIs prevention and control
globally in favor of ART and VCT
 Lack of integration of prevention and care activities for STIs (including
HIV) into sexual and reproductive health services
 Problem with syndromic Mx of women with vaginal discharge,
especially in low prevalence areas

311
Obstacles to Provision of Services…
 Intervention efforts to prevent STIs have failed to take into consideration
the full range of the underlying determinants
 Inability to ensure consistent supplies of STI medicines and condoms
 Counseling on risk reduction is also usually lacking
 Inadequate participation of partners, especially communities

312
Underlying Factors for Failure to Control STIs
 Ignorance and lack of information on STIs perpetuate wrong
conceptions of these diseases and associated stigmatization.
 Many STIs tend to be asymptomatic or otherwise unrecognized
until complications and sequelae develop, especially in women.
 The stigmatization associated with STIs (and clinics that provide STI
services) constitutes an ongoing and powerful barrier to the
implementation of STI prevention and care interventions.

Unwanted Pregnancy and Unsafe Abortion

Unwanted Pregnancy
• Unwanted pregnancy is a pregnancy that a woman is not actively trying
to have
• It could be
– Unintended
– Unplanned
– A mistake or
– Not at the right time

Reasons why a woman may not want a child
• May constrain her opportunities
➢Education
➢Employment
• Unwanted marriage
• Stigma
• Abandonment

Why unwanted pregnancy happen?
• Main reasons include
– Failure of contraceptive and family planning delivery systems
• Lack of information
• Lack of access
• Social/cultural/Religious barriers
– Violence
– Rape/Incest
– Lack of knowledge of sexuality and reproduction
– The method they were using failed.

Who is at risk of Unwanted pregnancy
• Married women
• Single women
• Adolescents and schoolgirls
• Rich and poor
• From Urban/Rural
All women are at risk!!!

The fate of women with unwanted pregnancies
• Increased morbidity/mortality
– Unsafe abortion
• Maternal death
• Complications of unsafe abortion
• Psycho-social problem
– Emotional
– Financial
– Physical

Why do women resort to unsafe abortion
• Restrictive laws
• Privacy
• Providers’ attitude toward safe abortion
• Other factors
– Provided in a special setup

Prevention Of Unwanted Pregnancy and Unsafe abortion
•Education on Sexuality and Reproductive Health
•Universal access to family planning
–Information
–Service
•Access to safe abortion

Grounds on Which Abortion is Permitted, revised abortion law of Ethiopia,
(House of Parliament, 2005)
 When the pregnancy puts the woman’s life at risk
 Fetal impairment or deformity
 When pregnancy follows Rape or incest (based on the woman’s complaint
only)
 When pregnancy occurs in minors (stated maternal age <18 years)
 The woman is physically and mentally unable to care for the would-be-
born child
322

Key elements of post-abortion care include:
1.Treatment of incomplete and unsafe abortion;
2. Counselling;
3. Family planning services;
4. Links to comprehensive reproductive health services; and
5. Community and service provider partnerships.
323

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