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

2. 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

3. 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.

4. 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.

5. 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.

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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 .

16. 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

17. 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)

18. 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

19. 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.

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

21. 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.

22. 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.

23. 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

24. 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

25. 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

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

27. Turkey and RH

28. “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

29. 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.

30. 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

31. 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

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

33. 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

34. 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

35. 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

36. 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.

37. 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).

40. 21.08.1984, Sağlık Bakanı Mehmet Aydın:

48. THANK YOU!