Concept of Reproductive Heath and How It is Delivered in General Health Services Dr. Yeşim YASİN Spring-2014

Outline Reproductive Health (RH) as a concept Components of RH new paradigm RH from human rights perspective Programmatic goals for RH How RH services are delivered in Turkey

Definition It is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to reproductive system and to its function and processes.

Revised definition RH addresses the reproductive processes, functions and system at all stages of life. It involves both men and women. RH implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.

Concept of RH RH care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being through preventing and serving reproductive health problems.

The concept implies that: Couples have the ability to reproduce and regulate their fertility with an access to safe, effective, affordable and acceptable methods Women are able to go through pregnancy and child birth safety Outcome of the pregnancy is successful in terms of maternal and infant well-being Couples are able to have sexual relations free of the fear of pregnancy and of contracting any disease

The reproductive life cycle Newborn Infancy- Youth Adult-Middle Age- Death Childhood Adolescence Elderly Sexual Activity Post-partum Pregnancy Childbirth

RH-Old Paradigm (before 1994) Family planning Unmet need for contraception Maternity care Antenatal care Safe child birth Post-partum care Child health care Breast feeding promotion Nutrition, growth monitoring Immunizations Sickness care (ORT, ARI, malaria, etc.) ORT-Oral Rehidratation Therapy ARI-Acute Respiratory tract Infections

RH New Paradigm (after the International Conference on Population and Development -ICPD, Cairo) Gender discrimination Sex selective abortions Son preference for food allocation, heath care, education, etc. Violence against women Child pornography Commercial sex Female genital mutilation Spouse abuse Rape, incest For the first time RH as a concept was mentioned in the ICPD, Cairo, in 1994

RH new paradigm-contd. 3. Adolescent sexuality 4. Reproductive rights regarding marriage and childbearing 5. Gender equity and equality 6. Unintended pregnancy 1. Emergency contraception 2. Safe abortions

RH new paradigm-contd. 7. Chronic complications of pregnancy and childbirth 8. STDs 1. Acute infections 2. Chronic complications (e.g. infertility, cervical cancer) 9. HIV/AIDS

Programmatic Goals for RH (WHO) Experience healthy sexual development and maturation Achieve desired number of children safely Avoid illness, disease and disability related to sexuality and reproduction Be free from violence, and other harmful practices.

Most problematic issues Unwanted pregnancy The complications of unsafe abortion The burden of contraception Who suffers the most? Among women of reproductive age 36% of all healthy years of life lost is due to RH problems whereas this rate is 12% for men.

It is estimated that: 87 million unplanned pregnancies occur Adolescent mothers account for 10% of all births 41 million unplanned pregnancies result in labor each year worldwide. In 2003, unplanned pregnancies accounted for 34% of all pregnancies all pregnancies in Turkey.

Equality and empowerment In order to make universal access to sexual and reproductive health a reality, it is essential to focus on gender equality and women’s empowerment .

Intersections between human rights, gender and culture greatly emphasized in area of sexual and reproductive health Cultural beliefs and attitudes have enormous impact on sexual and reproductive health choices Working from within a culture is essential

MDGs on RH Importance of reproductive health for achieving the MDGs recognized at the 2005 World Summit with the addition of a new target on universal access to reproductive health by 2015 under MDG 5 (improve maternal health)

Reproductive rights “Reproductive rights embrace certain human rights that are already recognized in national laws, international laws and international human rights documents and other consensus documents. These rights rest on the recognition of the basic rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes the right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.” — ICPD Programme of Action, para. 7.3

MDG 5 Goal 5 – Improve maternal health Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B: Achieve, by 2015, universal access to reproductive health.

Where are we now? The new target 5.B Maternal mortality The decline is still uneven: only 0.1% per 1990-2005 in sub-Saharan Africa Preventing unsafe abortion Minor decline which is attributable to increased contraceptive rates. Unsafe abortions contribute to 68 000 maternal deaths. Family planning The rate of unmet need for contraception is highest in sub-Saharan Africa

To achieve universal access to RH-1 Improving antenatal, delivery, postpartum and new-born care. Providing high-quality services for family planning, including infertility services. Eliminating unsafe abortion. Sexual and RH and HIV linkages.

To achieve universal access to RH-2 Strengthening research and programs capacity through partnership with countries. Promoting sexual health Combatting STIs, including HIV, reproductive tract infections (RTIs), cervical cancer and other gynecological morbidities.

Objectives of RH Meet the needs of RH and FP Prevent unwanted pregnancy Reduce high risk pregnancy, diseases and death Promote men participation Promote breastfeeding Prevent STDs

Objectives of RH (contd.) Gender equity Provide services and counseling to promote RH/SH in adolescents Reduce adolescent pregnancy and promote regular examinations Screen for/and recognize sexual abuse Non-judgmental, understanding & sensitive Recognize cultural differences & beliefs Respect sexual orientation

What RH services to be included Safe motherhood Family planning Prevention of maternal and perinatal morbidity & mortality Harmful practices Unwanted pregnancy Unsafe abortion Reproductive tract infections including STDs and HIV/AIDS Gender based violence Infertility Malnutrition & anemia Reproductive tract cancers

Factors affecting RH Economic circumstances Education Employment status Living conditions and family environment Social and gender relationships Traditional and legal structures

Turkey and RH

“Woman and RH” and “Child and Adolescent Health Services” Ministry of Health started to provide “Maternal and Child Health” services in 1930. 1952 Sub-Directorate (Şube Bşk.) 1963 Independent Directorate 1965 Law on Population Planning no. 557, General Directorate for Population Planning

1982 Merger of two directorates under “Maternal and Child Health and General Directorate of Family Planning (AÇSAP)” 1983 Law on “Evacuation of the Uterus and Sterilization Services Regulation on the Implementation and Inspection” enabling elective abortions until the 10th gestational week and voluntary sterilization.

In the 70’s maternal mortality rate was almost 200/100K; in 2010 it is 16/100K. In 1998, infant mortality rate was 42.7/1000; in 2010 it is 10/1000 With the development of Basic Sexual Health and RH (CSÜS) in the 90’s, MoH and EU implemented “RH Program of Turkey (TÜSP)” between 2003-2007.

Basic Service and Programs-1 Provision of Basic Approach to Neonatal Health Infant and Child Follow up Intensive Neonatal Care Screening Tests for Neonatal Care Maternal and Child Nutrition Child Infections Prevention Monitoring of Infant Deaths Hemoglobinopathy Control

Basic Service and Programs-2 Adolescent Health and Development Women Follow-up of 15-49 ages Pre-marital Consultancy Prenatal Care (DÖB) Mother Friendly Hospital Birth-C section Postnatal Care Emergency Obstetric Care (AOB)

Basic Service and Programs-3 Maternal Mortality Follow-up Family Planning Provision of Men’s Participation in -AÇSAP- Services In-Service RH Training Elderly RH

Primary Health Care All RH services are integrated in the primary health care system. Family Health Centers (ASM) and Community Health Centers (TSM) are responsible for Maternal and Child Health and Family Planning (AÇSAP) and RH (ÜS) Services

Community Health Centers Main aims include: to ensure that location and follow-up of pregnant/post-partum women and infants services are carried out in accordance with relevant protocols and criteria. to decrease maternal and infant mortality to maintain family planning services to increase the overall health status of women, mothers, infants and children

Community Health Centers-1 Ensure RH services are delivered by family physicians in accordance with preventative services guidelines. Ensure educational/training/course activities on theoretical and skills-related aspects. Makes plans to maintain RH services that are carried out by Family Health Centers. Provides education /training on IUDs and other theoretical and skills-related aspects on RH. Also provides adaptation training to health personnel.

Community Health Centers-2 Establishes collaboration between local governments and opinion leaders to plan and organize public education activities. Administers all programs implemented by the MoH to decrease maternal and child health (i.e. Guest Mum Project).

21.08.1984, Sağlık Bakanı Mehmet Aydın:

THANK YOU!