11th Postgraduate Course for Training in Reproductive Medicine and Reproductive Biology

From birth control to reproductive health

G. Benagiano
Istitute Superiore di Sanità, Roma, Italia

Dear friends,

Reproductive health - as you will soon hear - is in many ways the baby of the Special Programme of Research in Human Reproduction which is a prime co-sponsor of this course; as a former Director, for almost 5 years, of the Programme I am always happy to talk about reproductive health.

As you can imagine, this is a topic I have covered perhaps a dozen times since 1994 when the new concept was brought to world attention and prominence, thanks to the heated debate that surrounded it at the International Conference on Population and Development in Cairo.

I am fully aware of the many, compelling problems you have in promoting better health in your countries. At the same time, I would like to take your minds - for a moment - off all of your problems and ask you to reflect on the global picture of health in the world in the specific field of reproduction. A picture that - thanks to reproductive health - now integrates all activities in public health at the primary care level for any issue pertaining to reproduction. Getting this global picture will help you - I hope - in better understanding and therefore solving your own difficult problems.

It is self-evident that this new vision of health in the area of reproduction did not suddenly appear from nowhere. On the contrary, the text approved in Cairo evolved from a whole series of successive partial definitions and it is fair to state that WHO, as the global health agency of the world, played a unique role in arriving at the fine-tuned, final version.

I have already mentioned the role of the Special Programme; indeed, the term appeared for the first time in the Biennial Report 1986-1987 of the Special Programme of Research in Human Reproduction in the first chapter entitled Continuity and Change by the then Director, Dr. José Barzelatto.

Professor Mahmoud Fathalla - who later also became Director of the Special Programme - then provided, a first definition of Reproductive Health in another chapter of the same Report.

In the six years since the world community put reproductive health on its global agenda, a number of countries have tried to change their vertical family planning programmes into cross-cutting reproductive health ones. In other words, they have tried to move from Birth control to Reproductive health.

Worthy of special mention is the Government of India's decision to implement the Cairo plan of action by moving to an integrated approach to the population problem, abolishing "method-related targets" and replacing them with a wide range of contraceptive modalities.

The global reproductive health agenda is made up of many individual components that need to be properly integrated: The attainment of an equal status for women; universal access to family planning; promotion of safe motherhood and proper antenatal care; prevention of unsafe abortion; management of reproductive tract infections, HIV/AIDS and of infertility; (SLIDE 6) promotion of appropriate nutrition for mothers and their babies; infant and child health care; education of adolescents in sexuality and reproductive health; promotion of healthy and safe sexuality and elimination of harmful practices; attainment of an environment and working conditions protective of reproductive health.

There is one feature that specifically characterizes reproductive health as a global new vision in health and distinguishes it from all previous interventions: the promotion of the cause of women. I am told that - thanks to people like Ari Pinotti - in your country equality between men and women, although certainly far from being complete, has nonetheless made substantial progress. The situation is unfortunately worse in many developing countries where, not only women are often deprived of the freedom of making free choices in the vital area of reproduction, but are forced to live a life of inferior quality. Reproductive health is therefore an invaluable tool to achieve women's empowerment.

Addressing the Fourth World Conference on Women in Beijing in 1995, Dr Nakajima, then WHO's Director-General, stated:

"We are not asking for privileges for women. All we are saying is that equitable care is not identical care, particularly where physiological differences obviously call for specialized health services. Sustainable progress will be achieved when women are finally empowered to make free, informed and responsible choices, and assert themselves as leaders in their own right within their societies."

Indeed, when we look at the level of inequality between men and women still existing today in so many parts of the world, we must become ashamed of ourselves.

Women constitute only a third of the world's formal labour force, but they are responsible for two-thirds of the hours worked, whilst receiving only 10% of the world's income and owning less than 1% of the world's property.

There are many examples of how women suffer because of inequality; there is, however, one simple sentence that to me summarizes the essence of the problem: Referring to her own parents, a 16 year-old Pakistani girl recently pointed out:

"People here don't educate their girls because to them girls are not theirs. Girls are seen as belonging to their future in-laws' families and any investment in their future is futile. They go to their husbands' homes at a young age, usually anywhere from 13 to 17. The rest of their lives are spent looking after in-laws, and bearing and bringing up children to prolong and strengthen their husbands' family line".

The sentence not only shows the problem, but also points out the solution: education for girls and women. This, however, will take a long time and we cannot afford to just sit back and wait for women to receive full education. We must actively work to make all men aware of the situation in which so many women live today, because it seems more and more that half the world does not really know (and perhaps doesn't even care to know) how the other half lives!

We must therefore ensure that women become at least equal partners with men in any decisions about family size; at the same time, we must not forget that, in a world almost completely dominated by men in politics, economics, religion and the law, it will not be easy to convince those enjoying the advantages of a male dominated society to give away their privileges. Yet we must utilize education to promote reproductive health and equity for women. For instance, spreading the knowledge that pregnancy in young adolescents, births that are too closely spaced or occur at old age and high parities pose substantial risks to children, mothers, or both,

Education influences reproductive health in many different ways: a recent study conducted in Mexico among women of different degrees of literacy indicates a three-fold drop in the risk of maternal mortality with increased education. We all therefore share the responsibility of educating women and adolescents: we will help change their lives. One reason is that educated women are more likely to delay having children until after 20 years of age. It is a fact that formal education changes the reproductive patterns of women and improves the chances of adolescents to reach full development.

Because of its many negative consequences, child-bearing during adolescence has emerged as an issue of increasing concern throughout the developing and developed world. There is growing awareness that early child-bearing poses a health risk for the mother and the child and may truncate a girl's education, threatening her economic prospects, earning capacity and overall well-being. Unfortunately, it is estimated that still today, worldwide, about 15 million women aged 15-19 give birth each year and that about 11 percent of all babies are currently born to adolescents.

Educated women are also much more likely to use modern contraceptive methods than those with little or no education.

Finally, education transforms children from being an economic asset to becoming an economic liability because teenagers in school cannot earn a living; their parents will therefore be increasingly motivated to restrict family size. Traditionally, large families were also needed because of the very high perinatal and child mortality; if the parents see that the children they do have are likely to survive and become adults, their motivation for having many children will drop.

All of these considerations have led to one inescapable conclusion: our work must aim at "increasing informed choices in reproductive health for women". Instead to work to simply control births, we must work to teach men and women the advantages of properly planning their families. These advantages include better health for women

The World Bank has estimated that, for the age group 15-44, diseases related to reproduction (excluding cancer) amount to 33.50% of the total burden in women and only 10.80% in men.

Providing women with the freedom and the knowledge to make informed choices in their reproductive life, will also help to sustain the efforts of individual governments to achieve population stabilization, an urgent need in many countries, because the utilization of modern contraceptive methods will be the consequence of a free, informed decision and continuation of their use a sustainable effort.

This is why promoting reproductive health, far from downplaying the importance of family planning, will make it the centerpiece and will greatly help in eliminating the so-called "unmet need": couples who would like to limit their family, but have no access to modern methods.

As shown in this slide, this "unmet need" can be enormous.

Placing family planning within the context of reproductive health means recognizing that the rights and wishes of individuals are at the basis of the population issue and that each man and woman has a right to choose, away from any coercion or pressure.

Making contraceptive technology available to everybody in a health, rather than in a demographic context, means placing special emphasis on people, not methods; to quality of services, not simple distribution.

In this connection, there is an increasing awareness that family planning does help women in reducing health risks connected to reproductive events especially among the poor.

Families with fewer, healthier children can devote more resources to providing their children with adequate food, clothing, housing and educational opportunities.

The 1993 World Bank Development Report explicitly states that "Family planning services provided through community-based distribution are a highly cost-effective means of improving maternal and child health. In countries where both mortality and fertility are still relatively high, the cost per child-death-averted is extremely low".

It is this integration of maternal health, child health and adolescent health into primary health that represents the essence of reproductive health, through which we hope to transform the "population problem" into the "population solution".

The interdependence of the various components of reproductive health appears clear when we learn that it has been estimated that some 100,000 maternal deaths (between 20 and 25% of the total) could be avoided each year if all women who said they want no more children were able to stop childbearing.

We should all of us be ashamed of our inability to decrease maternal mortality over the last 30 years.

The United Nations estimated in 1990 that some five hundred and eighty-five thousand women died from causes related to pregnancy or delivery; ninety-nine percent of these deaths occurred in developing countries; the gap between the more and the less fortunate women is enormous: in Europe maternal death rates average 36 per 100,000 live births; in Africa they average 870 per 100,000, almost 25 times more. There are - according to the Weekly Epidemiological Record published by WHO on 19 April 1996 - eight countries where maternal death rates are 1500/100,000 or higher and four countries where the life time risk of dying because of a pregnancy is one in seven. This contrasts with seventeen countries where death rates are ten or less/100,000. During 1990 there were no deaths due to pregnancy in Iceland, Malta and Luxembourg.

Family planning also saves children's lives: as it appears from this slide, when children are born at intervals shorter than two years, mortality rates among them more than double.

Therefore, achieving an adequate birth spacing is a major health goal: in some countries it might reduce child death by up to one-third.

However, implementing the concept of reproductive health worldwide requires a change of the minds of health workers. We have succeeded in convincing governments of the need for a major paradigm shift, we have created an environment favourable to an integrated approach to primary health care in the area of reproduction, but the real battle will be fought at the level of the innumerous communities around the globe where these ideas need to become a reality.

We also need to change the minds of those in academia and in research.

Over the last thirty years, great progress has been made by research in the field of contraception: a number of very useful tools have been developed, as this slide reminds us.

More methods are coming, which will - hopefully - help in reaching everyone and become an essential tool in fighting a major reproductive evil: unsafe abortion.

The move from abortion to contraception must mobilize all of us, especially where voluntary abortion is illegal and therefore unsafe.

Ten years ago there were still between 40 and 60 million abortions being carried out in the world, possibly up to 40% of them illegally and many more practiced under unsafe if not frankly dangerous conditions, and I am afraid that not much has changed since.

Fighting unsafe abortion and its infectious complications leads me to talk about a major challenge for all of us specialists in gynaecology: reducing the burden of infertility.

From a research point of view infertility poses probably the most difficult challenge: in order for you to help all women in your country affected by infertility, simple, inexpensive interventions must be designed; exactly the opposite of what is happening worldwide.

The lack of simple, inexpensive treatments for infertility has very serious consequences in many parts of the world: When you think that almost two-thirds of the cases of infertility in sub-Saharan Africa are due to tubal occlusion, a well-known sequela of a pelvic infection, you realize that these women are condemned to infertility, as the thought of making IVF clinics available to all of them is weird.

Yet, we cannot abandon them: the social consequences of sterility in many setting, especially in Africa - and not only in Africa for that matter - are enormous.

These women are rejected by society, as well as their husbands, and end up marginalized, to say the least.

We have a moral obligation to help them. It is for this reason that I am happy to accept to speak at scientific meetings dealing with reproductive medicine: I have the duty to remind the specialists of the reality in which the vast majority of the women of the world live. We simply cannot overlook the millions of women condemned to infertility through pelvic infections - more often than not acquired from their partners through their extra-marital activities.

We must address the dichotomy we see today; on the one hand an ever increasing level of sophistication and therefore of cost of our new, exciting techniques of assisted reproduction, and on the other, the ever increasing need to find simple, inexpensive ways to help at least some of the millions of women of the developing world with infertility of tubal origin.

Is there something we can do to study ways to make assisted reproduction technology available in settings where at best we can utilize a simple ultrasound scanning, but certainly not GnRH analogues, or gonadotrophins, or any expensive instrumentation? I know that there is today no answer to this question; yet we cannot abandon the majority of infertile women, whether with anovulatory problems or tubal occlusion, to concentrate only on the more privileged.

I have tried to give you a real picture of the challenges posed by moving from simple birth control (a vertical, one theme, programme) to reproductive health (an horizontal global programme).

It is a picture probably very different from the one you expected. I have not described reproductive health as an exciting new field of scientific research.

Rather, I have tried to move all of you away for a minute from your urgent problems, to broaden your horizon, to look at the point of view of those who, all over the world, await help. I have asked you to put yourselves in their shoes, see their needs, hopes, fears, taboos, so that - having this broader picture - you can better address your specific present difficulties.

Having done that, I want to close by leaving you with a message of hope and optimism: if our knowledge is used with wisdom, compassion and understanding, we will one day be able to abolish not only disease, but also poverty, illiteracy, malnutrition, hunger and unemployment from the face of the planet. This, however, requires full commitment by all of us; I hope the world will be able to count on your commitment!

Thank you for your patience.