Early
Human
Development,
29 (1992)
35
35-42
Elsevier Scientific Publishers Ireland Ltd. EHD 01248
Reproductive health: a global overview M.F. Fathalla Special
Programme
of Research, Health
Development Organization,
and Research Training in Human 121 I Geneva 27 (Switzerland)
Reproduction,
World
Summary A global overview of reproductive health outlines major challenges for action. Worldwide, 60 million to 80 million couples suffer from infertility. At the same time, there is a striking unmet need for contraception in developing countries. Unsafe abortion practices result in between 115 000 and 204 000 deaths each year. Female genital mutilation in one form or another continues to exist in around 40 countries. A second generation of organisms has now made sexually transmitted diseases the most common group of notifiable diseases in most countries. For the year 2000, it is projected that there will be a cumulative total of about 40 million HIV infections in men, women and children. About half a million women die each year because of complications related to pregnancy and childbirth. A total of about 15 million infants and children die annually, mostly from preventable childhood diseases. At least 17% of all babies in developing countries are born with a low birth weight. Key words: reproduction;
health; world
Introduction The concept of Maternal and Child Health (MCH) has been the traditional public health approach to address the health needs in human reproduction. During the past few decades, new needs have emerged and expanded. Family planning is becoming a way of life and maternity the exception rather than the rule. A sexual revolution has resulted in a pandemic of sexually-transmitted bacterial and viral infections. Women have claimed their right to have their health needs addressed as women and not only as mothers. The traditional MCH approach can no longer respond to these new and expanded needs. The concept of reproductive health attempts to provide Correspondence to: Director, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland.
037%3782/92605.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
36
a comprehensive reproduction.
and integrated
approach
to the current
needs in human
Definition Health is defined in the Constitution of the World Health Organization (WHO) as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. In the context of this positive definition, reproductive health is a condition in which the reproductive process is accomplished in a state of complete physical, mental and social well-being and is not merely the absence of disease or disorders of the reproductive process. Reproductive health, therefore, apart from absence of disease, implies that people have the ability to reproduce, to regulate their fertility and to practice and enjoy sexual relationships. It further implies that reproduction is carried to a successful outcome through infant and child survival, growth and healthy development. It finally implies that women can go safely through pregnancy and childbirth, that fertility regulation can be achieved without health hazards and that people are safe in having sex [l]. Fertility The ability to reproduce is a basic element of reproductive health. Infertility in itself may not threaten physical health, but it can certainly have a serious impact on mental and social health. In many countries, the stigma of infertility often leads to mental disharmony, divorce and ostracism. The suffering experienced by infertile people can be very real. The WHO estimates that there are 60 million to 80 million infertile couples worldwide. Sub-Saharan Africa has one of the highest levels of fertility in the world. Paradoxically, it also has the highest level of infertility [2]. World Fertility Survey data in 22 countries in sub-Saharan Africa on childlessness at the end of the childbearing period showed a range from 2.6% to 32%, with a weighted average of 10.1% for all countries. The highest rates were in the central African zone (the infertility belt): Gabon (32%), parts of Zaire (20.5%), the Central African Republic (17.3%), Congo (20.5%) and the United Republic of Cameroon (14.7%). Comparable figures from the World Fertility Survey in 27 other developing countries show rates ranging from 1.3% to 6.7%, with an average of 3.4%. Studies supported by the WHO Special Programme of Research, Development and Research Training in Human Reproduction confirm that the high levels of infertility in Africa are caused by infections, most particularly by means of sexual transmission of Neisseria gonorrhoea and Chlamydia trachomatis. Both organisms cause symptomless infections in women, both are implicated in ascending infections of the genital tract and both carry a risk of tubal occlusion and adhesions that rises sharply with chronicity and re-infection. The evidence of the important role of gonorrhoea has been known for some time. However, the equivalent prevalence of Chlamydia with possibly more severe consequences was recognized only recently.
31
Fertility regulation Contraceptive prevalence, defined as the percentage of married women of reproductive age who are using (or whose husbands are using) any form of contraception rose during the period from 1965-1970 to 1985-1990 from 9% to 50%. East Asia’s advances have been most spectacular and even exceeded the developed country average. Even in Africa, as a whole, contraceptive prevalence almost trebled from 5% to 14% [3]. The total number of contraceptive users in developing countries is estimated to have increased from 3 1 million in 1960- 1965 to 38 1 million in 1985- 1990 [3]. The numbers and the increase varied in different regions. While in East Asia, it increased from 18 to 217 million, in Africa it increased from 2 to 18 million. Even with no increase in contraceptive prevalence beyond the current 51% level, an increase of contraceptive users by about 108 million should be expected by the year 2000, because of the increased number of married women of reproductive age [31. Current population projections estimate that contraceptive prevalence in developing countries can be expected to increase to 59% by the year 2000, with a decline in total fertility rate to 3.3%. This would translate to an increase in contraceptive use by 186 million, to a total of about 567 million [3]. A corresponding expansion in services will be needed. Methods of contraception can be grouped,’ from a service point of view, into ‘clinic’, ‘supply’ and ‘non-supply’ methods. Clinic methods include male and female sterilization, intrauterine devices (IUDs), injectables, implants and the pill. Supply methods include condoms and female barrier methods (diaphragm, cervical cap, spermicidal foams, creams, jellies and sponges). Non-supply methods include rhythm or periodic abstinence and withdrawal (coitus interruptus). Clinic and supply methods account for approximately 80% of contraceptive practice worldwide. These methods make up a larger fraction of contraceptive use in developing than in developed countries - about 90% and 65%, respectively [4]. This may reflect the differing history of contraceptive practice in the two groups of countries. Whereas in most developed countries, marital fertility reached low levels before modem contraceptives were invented, in most developing countries contraception did not become widespread until modem methods were available and these methods tended to be preferred by new users from the start. There is also another rationale for this difference. Modem methods, particularly clinic methods, are much more effective but can be associated with some health risks. Where pregnancy termination services are widely and safely available and where the health risks of continuing pregnancy and childbirth are negligible, a relatively lower level of effectiveness is an acceptable trade-off for a convenient and a safe method. The situation in most developing countries, on the other hand, is such that a contraceptive failure can be a major health hazard. Barrier methods of contraception, the condom in particular, also offer the advantage of protection against sexually transmitted diseases, the actual and/or perceived risk of which is still different between developed countries and a majority of developing country populations.
38
Overall, voluntary surgical contraception, intra-uterine devices and oral pills, are the most widely used contraceptives, worldwide [4]. There are, however, pronounced regional variations. Data from the World Fertility Survey carried out in 41 developing countries between 1972 and 1984 revealed a striking unmet need for contraception [5]. In Africa, less than a quarter of women who stated that they did not want any more births are practicing contraception, in Asia 43% and in Latin America 57%. These figures, even when interpreted with caution, imply an inadequate supply of contraception to women who want it. A recent study attempted to provide a projection of the size of the population in developing countries if all unwanted births were prevented from 1990 onward [6]. The differences from the World Bank standard projections amounted to 1.5 billion by the year 2050 (i.e. 7.5 billion instead of 9) and to 2.2 billion by the year 2100 (i.e. 7.8 billion instead of 10). These are of course upper limits for what can be achieved, since it will not be practically possible to eliminate all unwanted pregnancies. Figures for induced abortion provide another indication of the level of unmet need for family planning in developing countries, even taking into consideration that not all women with unwanted pregnancy would resort to induced abortion, particularly in developing countries where services are not widely available or are not permitted by the legal system. With a worldwide estimate of 36-53 million induced abortions performed each year (an annual rate of 32-46 abortions per 1000 women of reproductive age), the magnitude of the problem of unwanted pregnancy and the unmet need for family planning can be appreciated [7]. The World Health Organization estimates that out of the 500 000 maternal deaths that occur worldwide annually, probably between 115 000 and 204 000 result from complications of unsafe abortion practices [8]. The WHO estimates that more than half of the deaths caused by induced abortion occur in South and South East Asia; the next largest proportion taking place in sub-Saharan Africa. The numbers are only approximations because of the difficulty in distinguishing between deaths from induced abortion and those from spontaneous abortion in countries where induced abortion is illegal. In view of the major worldwide expansion in the use of modern methods of fertility regulation, safety has become a public health concern. In developed countries, where the number of women using contraceptives is much larger than the number of those who are pregnant and where maternal mortality ratios are very low, reproductive mortality attributable to contraceptive use assumes a relatively large dimension. In developing countries reproductive mortality attributable to contraceptive use is still insignificant compared with maternal mortality. Evaluation of the safety of contraceptive methods has to take into consideration not only the health hazards associated with their use, but also their effectiveness and their non-contraceptive health benefits. Assessment of risk/benefit ratio of contraceptive methods will differ for different populations, for different individuals and even for the same individual at different periods in life. The importance attached to effectiveness depends on the level of health risk associated with the pregnancy it is meant to avert. This risk will vary in different populations largely in relation to two main factors: the maternal mortality ratio and the availability of legal, quality ser-
39
vices for induced abortion. Where maternal mortality and morbidity risks are high, as is the situation in most of the developing world, failure of a contraceptive can carry a considerable risk of maternal death from a pregnancy that was not planned or wanted. If quality services for termination of pregnancy are available and accessible, the use of a less effective contraceptive would not carry a significant health risk. The use of this same type of contraceptive, in situations where induced abortion is not available, though, could mean a high risk due to the need for unsafe abortion. Sexuality The ability to engage in a mutually fullilling sexual relationship is an important element in reproductive health. Data, however, are scarce on sexual health. Until recently and still in many societies, the subject has been taboo. The World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction has started a global research initiative in developing countries on sexual behaviour. One public health problem in this context is female genital mutilation, often referred to as female circumcision. The term ‘female circumcision’ is misleading. It implies an operation similar to male circumcision - simply the removal of a piece of skin. This is often not the case in the female, where a large amount of healthy sensitive tissue is commonly removed. In its extreme form, known as infibulation, the procedure involves the removal of all the external genitalia and the stitching up of the two sides of the vulva to leave only a tiny opening for the passage of urine and menstrual blood [9]. The practice of female genital mutilation, in one form or another, continues to exist in around 40 countries, mostly in East and West Africa and parts of the Arabian Peninsula. With immigration, it is now also practiced in Europe and North America. It is estimated that some 80 million women around the world have been subjected to this practice [9]. Because the procedure is often performed outside the medical system it can also have potentially serious physical health consequences. The origin of the practice is lost in antiquity, but the underlying rationale is that it attenuates sexual desire, thus ‘saving’ the girl from temptation and preserving her fidelity. Several countries have enacted laws to forbid the procedure. However, with a deep-rooted tradition, national and community education campaigns are needed. Sexually transmitted diseases Communicable diseases that are transmitted predominantly by sexual contact are now the most common group of notifiable diseases in most countries, particularly in the age group of 15 to 50 years and in infants. Despite some fluctuations in their incidence, they continue to occur at unacceptably high levels [lo]. During the last 40 years, the burden of a number of traditional venereal diseases like gonorrhoea, syphilis and chancroid has declined, particularly in industrialized countries, but they have been amply replaced by both bacterial and viral syndromes associated with Chlamydia trachomatis, human (alpha) herpes virus, human papillomavirus and human immunodeficiency virus [lo]. These agents, regarded as
40
the second generation of sexually transmitted organisms, are frequently more difficult to identify, treat and control and they can cause serious complications, some of which result in chronic ill health, disability and death. Both groups of STDs remain major health problems in most developing countries. Reliable data on worldwide incidence of STDs are not available. WHO minimal estimates of yearly incidence for major bacterial STDs are 80.5 million and for viral diseases (not including HIV infection) 50 million [1 11. Trichomoniases, which is of much less public health importance than the bacterial and viral STDs, has an estimated annual incidence of 120 million cases. STDs, by definition, affect both men and women. However, STDs have more serious sequelae in women than in men. For one reason, early detection and hence early treatment is easier in the male. The lesions are often hidden and may be asymptomatic, in women. For another reason, ascending infection is much more serious in the woman and more likely to occur leading to pelvic inflammatory disease, permanent infertility and risk of ectopic pregnancy. Even cancer of the cervix can be a late sequela. Another consideration is the transmission to foetus of several pathogens of STDs. It is also not sufficiently realized that the transmission risk is more from man to woman. The current effective barrier method for protection against STDs is the male condom. Female barrier methods currently available are more effective for the prevention of pregnancy than for the prevention of STDs. The global HIV/AIDS
situation
As of April 1991, over 345 000 cases of acquired immunodeticiency syndrome (AIDS) have been reported to the World Health Organization (WHO) from 162 countries and, territories [12]. Taking into account under-diagnosis, under-reporting and delays in reporting, WHO estimates that more than one million adult AIDS cases may have occurred worldwide since the beginning of the pandemic. In addition, it is estimated that by early 1991 more than 500 000 paediatric AIDS cases resulting from perinatal transmission may have occurred, with over 90% of this total in sub-Saharan Africa. Perinatal transmission of the human immunodeficiency virus (HIV) - that is, spread of HIV from an infected mother to her foetus or newborn baby - occurs in approximately one-third of pregnancies. Thus WHO estimates that the cumulative global total of AIDS cases as of early 1991 is more than 1.5 million. By April 1991, at least S- 10 million HIV infections may have occurred in adults worldwide and about one million children may have been born infected with HIV. While the HIV infection rate appears to be slowing in some industrialized countries, the incidence of new infections is increasing markedly in developing countries, especially in sub-Saharan Africa, but also in Asia, Latin America and the Caribbean. AIDS, the end-stage of infection with HIV, takes 10 years on average to develop. Because of this long lag time, AIDS cases will continue to develop from the existing pool of HIV-infected persons for some time to come, no matter how successful our efforts to curb the further spread of HIV. For the year 2000, WHO projects a cumulative total of close to 30 million adult HIV infections, of which more than 90% will be in developing countries [ 121. During the same decade, WHO projects that 10 million or more children will have been born
41
with HIV, the majority of them in sub-Saharan Africa. For the year 2000, WHO’s current projection is that there will be a cumulative total of about 40 million HIV infections in men, women and children. The cumulative total of adult AIDS cases projected by WHO for the year 2000 is close to 10 million, of which almost 90% will be in the developing countries. In addition to the 10 million children infected with HIV by the end of the decade, it is expected that more than 10 million children will be orphaned during the 1990s as their mothers or both parents die of AIDS [12]. The pandemic will have a particularly dramatic impact on the developing countries. Already overburdened health facilities risk being overwhelmed altogether. Through the deaths of millions of young and middle-aged adults, over 10 million children will be orphaned and the elderly left without support. The deaths of these adults, who include members of social, economic and political elites, could lead to economic and even political destabilization. As of early 1991, about 70% of all global HIV infections are estimated to have been spread by sexual intercourse between men and women [12]. By the end of the century, it is projected that over 80% of all HIV infections will result from heterosexual intercourse. With more than 3 million women estimated to be infected, the problem of perinatal transmission has become acute. Safe motbertkood In many parts of the world, maternal mortality rates have been reduced to levels as low 2 per 100 000 live births. In other parts of the world, rates up to 1100 are still encountered [ 131. WHO global estimates indicate that about half a million women die each year because of complications related to pregnancy and childbirth. All but about 6000 of these deaths take place in developing countries [ 131. Moreover, maternal mortality should be looked upon as just the tip of an iceberg of maternal morbidity, suffering and ill-health. Infant and child survival, growth and development It is estimated that about 9.8 million infants and about 5 million children aged l-4 years, a total of about 15 million, died annually in the world during the period 1985 1990 [ 111. These alarming figures do not reveal the magnitude of morbidity and impairment of growth and development of those who survive. Preventable childhood diseases - such as measles, polio, tetanus, tuberculosis, whooping cough and diphtheria, against which there are effective vaccines and diarrhoeal diseases, pneumonia and other acute respiratory tract infections that can be prevented or effectively treated through relatively low-cost remedies - are currently responsible for the great majority of the world’s millions of deaths of children under 5 years and disability of millions more every year. Besides these readily preventable or treatable diseases and some others such as malaria, which have proved more difficult to combat, children today are faced with the new spectre of the AIDS
42
pandemic. In the most seriously affected countries HIV/AIDS gains of child survival programmes.
threatens to offset the
Low birth weight Low birth weight (less than 2500 g) is a sensitive indicator for predicting the chance of both infant survival and healthy child growth and development. It also reflects the present and past health status of the mother. WHO global estimates of low birth weight show that some 20 million of the 129 million infants born in 1985 had a low birth weight: about 19 million or 17% of all live births in developing countries [ll]. Low birth weight infants born in developed countries are mostly pre-term babies, but the great majority of such infants born in developing countries are small-fordate, which, means they are delivered in term but have suffered intrauterine growth retardation. References 1 Fathalla, M.F. (1988): Promotion of research in human reproduction: Global needs and perspectives. Hum. Reprod., 3, 7-10. 2 Frank, 0. (1983): Infertility in sub-Saharan Africa: Estimates and implications. Popul. Dev. Rev., 9, 137-144. 3 United Nations (1991): United Nations Population Fund: The State of World Population. UNFPA, New York. 4 United Nations (1989): United Nations Department of International Economics and Social Affairs: Levels and trends of contraceptive use as assessedin 1988. Population Studies 1989, No. 110. United Nations, New York. 5 United Nations (1990): United Nations Population Fund. The State of World Population 1990. UNPA, New York. 6 Bongaarts, J. (1990): The measurement of wanted fertility. Popul. Dev. Rev., 16, 487-506. I Henshaw, S.K. (1990): Induced abortion: A world review, 1990. Int. Fam. Plann. Persp., 16, 59-65. 8 World Health Organization (1990): World Health Organization, Division of Family Health: Abortion: A tabulation of available data on the frequency and mortality of unsafe abortion. WHO/MCH/90. 14, 1990. WHO, Geneva. Armstrong, S. (1991): Female circumcision: fighting a cruel tradition. New Sci., 2 Feb. Schryver De, A. and Meheus, A. (1990): Epidemiology of sexually transmitted diseases: the global picture. Bull. W.H.O., 68, 639-654. World Health Organization (1990): World Health Organization, Division of Epidemiological Surveillance and Health Situation and Trend Assessment 1990. Global estimates for health situation assessment and projections. WHO/HST/90, 2. WHO, Geneva. World Health Organization (1991): The global HIV/AIDS situation. In Point of Fact No. 74. WHO, Geneva. World Health Organization (1986): World Health Organization, Division of Family Health 1986. Maternity Mortality Rates. A tabulation of available information, 2nd Edn. WHO, Geneva.
Human
Development,
29 (1992)
35
35-42
Elsevier Scientific Publishers Ireland Ltd. EHD 01248
Reproductive health: a global overview M.F. Fathalla Special
Programme
of Research, Health
Development Organization,
and Research Training in Human 121 I Geneva 27 (Switzerland)
Reproduction,
World
Summary A global overview of reproductive health outlines major challenges for action. Worldwide, 60 million to 80 million couples suffer from infertility. At the same time, there is a striking unmet need for contraception in developing countries. Unsafe abortion practices result in between 115 000 and 204 000 deaths each year. Female genital mutilation in one form or another continues to exist in around 40 countries. A second generation of organisms has now made sexually transmitted diseases the most common group of notifiable diseases in most countries. For the year 2000, it is projected that there will be a cumulative total of about 40 million HIV infections in men, women and children. About half a million women die each year because of complications related to pregnancy and childbirth. A total of about 15 million infants and children die annually, mostly from preventable childhood diseases. At least 17% of all babies in developing countries are born with a low birth weight. Key words: reproduction;
health; world
Introduction The concept of Maternal and Child Health (MCH) has been the traditional public health approach to address the health needs in human reproduction. During the past few decades, new needs have emerged and expanded. Family planning is becoming a way of life and maternity the exception rather than the rule. A sexual revolution has resulted in a pandemic of sexually-transmitted bacterial and viral infections. Women have claimed their right to have their health needs addressed as women and not only as mothers. The traditional MCH approach can no longer respond to these new and expanded needs. The concept of reproductive health attempts to provide Correspondence to: Director, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland.
037%3782/92605.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
36
a comprehensive reproduction.
and integrated
approach
to the current
needs in human
Definition Health is defined in the Constitution of the World Health Organization (WHO) as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. In the context of this positive definition, reproductive health is a condition in which the reproductive process is accomplished in a state of complete physical, mental and social well-being and is not merely the absence of disease or disorders of the reproductive process. Reproductive health, therefore, apart from absence of disease, implies that people have the ability to reproduce, to regulate their fertility and to practice and enjoy sexual relationships. It further implies that reproduction is carried to a successful outcome through infant and child survival, growth and healthy development. It finally implies that women can go safely through pregnancy and childbirth, that fertility regulation can be achieved without health hazards and that people are safe in having sex [l]. Fertility The ability to reproduce is a basic element of reproductive health. Infertility in itself may not threaten physical health, but it can certainly have a serious impact on mental and social health. In many countries, the stigma of infertility often leads to mental disharmony, divorce and ostracism. The suffering experienced by infertile people can be very real. The WHO estimates that there are 60 million to 80 million infertile couples worldwide. Sub-Saharan Africa has one of the highest levels of fertility in the world. Paradoxically, it also has the highest level of infertility [2]. World Fertility Survey data in 22 countries in sub-Saharan Africa on childlessness at the end of the childbearing period showed a range from 2.6% to 32%, with a weighted average of 10.1% for all countries. The highest rates were in the central African zone (the infertility belt): Gabon (32%), parts of Zaire (20.5%), the Central African Republic (17.3%), Congo (20.5%) and the United Republic of Cameroon (14.7%). Comparable figures from the World Fertility Survey in 27 other developing countries show rates ranging from 1.3% to 6.7%, with an average of 3.4%. Studies supported by the WHO Special Programme of Research, Development and Research Training in Human Reproduction confirm that the high levels of infertility in Africa are caused by infections, most particularly by means of sexual transmission of Neisseria gonorrhoea and Chlamydia trachomatis. Both organisms cause symptomless infections in women, both are implicated in ascending infections of the genital tract and both carry a risk of tubal occlusion and adhesions that rises sharply with chronicity and re-infection. The evidence of the important role of gonorrhoea has been known for some time. However, the equivalent prevalence of Chlamydia with possibly more severe consequences was recognized only recently.
31
Fertility regulation Contraceptive prevalence, defined as the percentage of married women of reproductive age who are using (or whose husbands are using) any form of contraception rose during the period from 1965-1970 to 1985-1990 from 9% to 50%. East Asia’s advances have been most spectacular and even exceeded the developed country average. Even in Africa, as a whole, contraceptive prevalence almost trebled from 5% to 14% [3]. The total number of contraceptive users in developing countries is estimated to have increased from 3 1 million in 1960- 1965 to 38 1 million in 1985- 1990 [3]. The numbers and the increase varied in different regions. While in East Asia, it increased from 18 to 217 million, in Africa it increased from 2 to 18 million. Even with no increase in contraceptive prevalence beyond the current 51% level, an increase of contraceptive users by about 108 million should be expected by the year 2000, because of the increased number of married women of reproductive age [31. Current population projections estimate that contraceptive prevalence in developing countries can be expected to increase to 59% by the year 2000, with a decline in total fertility rate to 3.3%. This would translate to an increase in contraceptive use by 186 million, to a total of about 567 million [3]. A corresponding expansion in services will be needed. Methods of contraception can be grouped,’ from a service point of view, into ‘clinic’, ‘supply’ and ‘non-supply’ methods. Clinic methods include male and female sterilization, intrauterine devices (IUDs), injectables, implants and the pill. Supply methods include condoms and female barrier methods (diaphragm, cervical cap, spermicidal foams, creams, jellies and sponges). Non-supply methods include rhythm or periodic abstinence and withdrawal (coitus interruptus). Clinic and supply methods account for approximately 80% of contraceptive practice worldwide. These methods make up a larger fraction of contraceptive use in developing than in developed countries - about 90% and 65%, respectively [4]. This may reflect the differing history of contraceptive practice in the two groups of countries. Whereas in most developed countries, marital fertility reached low levels before modem contraceptives were invented, in most developing countries contraception did not become widespread until modem methods were available and these methods tended to be preferred by new users from the start. There is also another rationale for this difference. Modem methods, particularly clinic methods, are much more effective but can be associated with some health risks. Where pregnancy termination services are widely and safely available and where the health risks of continuing pregnancy and childbirth are negligible, a relatively lower level of effectiveness is an acceptable trade-off for a convenient and a safe method. The situation in most developing countries, on the other hand, is such that a contraceptive failure can be a major health hazard. Barrier methods of contraception, the condom in particular, also offer the advantage of protection against sexually transmitted diseases, the actual and/or perceived risk of which is still different between developed countries and a majority of developing country populations.
38
Overall, voluntary surgical contraception, intra-uterine devices and oral pills, are the most widely used contraceptives, worldwide [4]. There are, however, pronounced regional variations. Data from the World Fertility Survey carried out in 41 developing countries between 1972 and 1984 revealed a striking unmet need for contraception [5]. In Africa, less than a quarter of women who stated that they did not want any more births are practicing contraception, in Asia 43% and in Latin America 57%. These figures, even when interpreted with caution, imply an inadequate supply of contraception to women who want it. A recent study attempted to provide a projection of the size of the population in developing countries if all unwanted births were prevented from 1990 onward [6]. The differences from the World Bank standard projections amounted to 1.5 billion by the year 2050 (i.e. 7.5 billion instead of 9) and to 2.2 billion by the year 2100 (i.e. 7.8 billion instead of 10). These are of course upper limits for what can be achieved, since it will not be practically possible to eliminate all unwanted pregnancies. Figures for induced abortion provide another indication of the level of unmet need for family planning in developing countries, even taking into consideration that not all women with unwanted pregnancy would resort to induced abortion, particularly in developing countries where services are not widely available or are not permitted by the legal system. With a worldwide estimate of 36-53 million induced abortions performed each year (an annual rate of 32-46 abortions per 1000 women of reproductive age), the magnitude of the problem of unwanted pregnancy and the unmet need for family planning can be appreciated [7]. The World Health Organization estimates that out of the 500 000 maternal deaths that occur worldwide annually, probably between 115 000 and 204 000 result from complications of unsafe abortion practices [8]. The WHO estimates that more than half of the deaths caused by induced abortion occur in South and South East Asia; the next largest proportion taking place in sub-Saharan Africa. The numbers are only approximations because of the difficulty in distinguishing between deaths from induced abortion and those from spontaneous abortion in countries where induced abortion is illegal. In view of the major worldwide expansion in the use of modern methods of fertility regulation, safety has become a public health concern. In developed countries, where the number of women using contraceptives is much larger than the number of those who are pregnant and where maternal mortality ratios are very low, reproductive mortality attributable to contraceptive use assumes a relatively large dimension. In developing countries reproductive mortality attributable to contraceptive use is still insignificant compared with maternal mortality. Evaluation of the safety of contraceptive methods has to take into consideration not only the health hazards associated with their use, but also their effectiveness and their non-contraceptive health benefits. Assessment of risk/benefit ratio of contraceptive methods will differ for different populations, for different individuals and even for the same individual at different periods in life. The importance attached to effectiveness depends on the level of health risk associated with the pregnancy it is meant to avert. This risk will vary in different populations largely in relation to two main factors: the maternal mortality ratio and the availability of legal, quality ser-
39
vices for induced abortion. Where maternal mortality and morbidity risks are high, as is the situation in most of the developing world, failure of a contraceptive can carry a considerable risk of maternal death from a pregnancy that was not planned or wanted. If quality services for termination of pregnancy are available and accessible, the use of a less effective contraceptive would not carry a significant health risk. The use of this same type of contraceptive, in situations where induced abortion is not available, though, could mean a high risk due to the need for unsafe abortion. Sexuality The ability to engage in a mutually fullilling sexual relationship is an important element in reproductive health. Data, however, are scarce on sexual health. Until recently and still in many societies, the subject has been taboo. The World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction has started a global research initiative in developing countries on sexual behaviour. One public health problem in this context is female genital mutilation, often referred to as female circumcision. The term ‘female circumcision’ is misleading. It implies an operation similar to male circumcision - simply the removal of a piece of skin. This is often not the case in the female, where a large amount of healthy sensitive tissue is commonly removed. In its extreme form, known as infibulation, the procedure involves the removal of all the external genitalia and the stitching up of the two sides of the vulva to leave only a tiny opening for the passage of urine and menstrual blood [9]. The practice of female genital mutilation, in one form or another, continues to exist in around 40 countries, mostly in East and West Africa and parts of the Arabian Peninsula. With immigration, it is now also practiced in Europe and North America. It is estimated that some 80 million women around the world have been subjected to this practice [9]. Because the procedure is often performed outside the medical system it can also have potentially serious physical health consequences. The origin of the practice is lost in antiquity, but the underlying rationale is that it attenuates sexual desire, thus ‘saving’ the girl from temptation and preserving her fidelity. Several countries have enacted laws to forbid the procedure. However, with a deep-rooted tradition, national and community education campaigns are needed. Sexually transmitted diseases Communicable diseases that are transmitted predominantly by sexual contact are now the most common group of notifiable diseases in most countries, particularly in the age group of 15 to 50 years and in infants. Despite some fluctuations in their incidence, they continue to occur at unacceptably high levels [lo]. During the last 40 years, the burden of a number of traditional venereal diseases like gonorrhoea, syphilis and chancroid has declined, particularly in industrialized countries, but they have been amply replaced by both bacterial and viral syndromes associated with Chlamydia trachomatis, human (alpha) herpes virus, human papillomavirus and human immunodeficiency virus [lo]. These agents, regarded as
40
the second generation of sexually transmitted organisms, are frequently more difficult to identify, treat and control and they can cause serious complications, some of which result in chronic ill health, disability and death. Both groups of STDs remain major health problems in most developing countries. Reliable data on worldwide incidence of STDs are not available. WHO minimal estimates of yearly incidence for major bacterial STDs are 80.5 million and for viral diseases (not including HIV infection) 50 million [1 11. Trichomoniases, which is of much less public health importance than the bacterial and viral STDs, has an estimated annual incidence of 120 million cases. STDs, by definition, affect both men and women. However, STDs have more serious sequelae in women than in men. For one reason, early detection and hence early treatment is easier in the male. The lesions are often hidden and may be asymptomatic, in women. For another reason, ascending infection is much more serious in the woman and more likely to occur leading to pelvic inflammatory disease, permanent infertility and risk of ectopic pregnancy. Even cancer of the cervix can be a late sequela. Another consideration is the transmission to foetus of several pathogens of STDs. It is also not sufficiently realized that the transmission risk is more from man to woman. The current effective barrier method for protection against STDs is the male condom. Female barrier methods currently available are more effective for the prevention of pregnancy than for the prevention of STDs. The global HIV/AIDS
situation
As of April 1991, over 345 000 cases of acquired immunodeticiency syndrome (AIDS) have been reported to the World Health Organization (WHO) from 162 countries and, territories [12]. Taking into account under-diagnosis, under-reporting and delays in reporting, WHO estimates that more than one million adult AIDS cases may have occurred worldwide since the beginning of the pandemic. In addition, it is estimated that by early 1991 more than 500 000 paediatric AIDS cases resulting from perinatal transmission may have occurred, with over 90% of this total in sub-Saharan Africa. Perinatal transmission of the human immunodeficiency virus (HIV) - that is, spread of HIV from an infected mother to her foetus or newborn baby - occurs in approximately one-third of pregnancies. Thus WHO estimates that the cumulative global total of AIDS cases as of early 1991 is more than 1.5 million. By April 1991, at least S- 10 million HIV infections may have occurred in adults worldwide and about one million children may have been born infected with HIV. While the HIV infection rate appears to be slowing in some industrialized countries, the incidence of new infections is increasing markedly in developing countries, especially in sub-Saharan Africa, but also in Asia, Latin America and the Caribbean. AIDS, the end-stage of infection with HIV, takes 10 years on average to develop. Because of this long lag time, AIDS cases will continue to develop from the existing pool of HIV-infected persons for some time to come, no matter how successful our efforts to curb the further spread of HIV. For the year 2000, WHO projects a cumulative total of close to 30 million adult HIV infections, of which more than 90% will be in developing countries [ 121. During the same decade, WHO projects that 10 million or more children will have been born
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with HIV, the majority of them in sub-Saharan Africa. For the year 2000, WHO’s current projection is that there will be a cumulative total of about 40 million HIV infections in men, women and children. The cumulative total of adult AIDS cases projected by WHO for the year 2000 is close to 10 million, of which almost 90% will be in the developing countries. In addition to the 10 million children infected with HIV by the end of the decade, it is expected that more than 10 million children will be orphaned during the 1990s as their mothers or both parents die of AIDS [12]. The pandemic will have a particularly dramatic impact on the developing countries. Already overburdened health facilities risk being overwhelmed altogether. Through the deaths of millions of young and middle-aged adults, over 10 million children will be orphaned and the elderly left without support. The deaths of these adults, who include members of social, economic and political elites, could lead to economic and even political destabilization. As of early 1991, about 70% of all global HIV infections are estimated to have been spread by sexual intercourse between men and women [12]. By the end of the century, it is projected that over 80% of all HIV infections will result from heterosexual intercourse. With more than 3 million women estimated to be infected, the problem of perinatal transmission has become acute. Safe motbertkood In many parts of the world, maternal mortality rates have been reduced to levels as low 2 per 100 000 live births. In other parts of the world, rates up to 1100 are still encountered [ 131. WHO global estimates indicate that about half a million women die each year because of complications related to pregnancy and childbirth. All but about 6000 of these deaths take place in developing countries [ 131. Moreover, maternal mortality should be looked upon as just the tip of an iceberg of maternal morbidity, suffering and ill-health. Infant and child survival, growth and development It is estimated that about 9.8 million infants and about 5 million children aged l-4 years, a total of about 15 million, died annually in the world during the period 1985 1990 [ 111. These alarming figures do not reveal the magnitude of morbidity and impairment of growth and development of those who survive. Preventable childhood diseases - such as measles, polio, tetanus, tuberculosis, whooping cough and diphtheria, against which there are effective vaccines and diarrhoeal diseases, pneumonia and other acute respiratory tract infections that can be prevented or effectively treated through relatively low-cost remedies - are currently responsible for the great majority of the world’s millions of deaths of children under 5 years and disability of millions more every year. Besides these readily preventable or treatable diseases and some others such as malaria, which have proved more difficult to combat, children today are faced with the new spectre of the AIDS
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pandemic. In the most seriously affected countries HIV/AIDS gains of child survival programmes.
threatens to offset the
Low birth weight Low birth weight (less than 2500 g) is a sensitive indicator for predicting the chance of both infant survival and healthy child growth and development. It also reflects the present and past health status of the mother. WHO global estimates of low birth weight show that some 20 million of the 129 million infants born in 1985 had a low birth weight: about 19 million or 17% of all live births in developing countries [ll]. Low birth weight infants born in developed countries are mostly pre-term babies, but the great majority of such infants born in developing countries are small-fordate, which, means they are delivered in term but have suffered intrauterine growth retardation. References 1 Fathalla, M.F. (1988): Promotion of research in human reproduction: Global needs and perspectives. Hum. Reprod., 3, 7-10. 2 Frank, 0. (1983): Infertility in sub-Saharan Africa: Estimates and implications. Popul. Dev. Rev., 9, 137-144. 3 United Nations (1991): United Nations Population Fund: The State of World Population. UNFPA, New York. 4 United Nations (1989): United Nations Department of International Economics and Social Affairs: Levels and trends of contraceptive use as assessedin 1988. Population Studies 1989, No. 110. United Nations, New York. 5 United Nations (1990): United Nations Population Fund. The State of World Population 1990. UNPA, New York. 6 Bongaarts, J. (1990): The measurement of wanted fertility. Popul. Dev. Rev., 16, 487-506. I Henshaw, S.K. (1990): Induced abortion: A world review, 1990. Int. Fam. Plann. Persp., 16, 59-65. 8 World Health Organization (1990): World Health Organization, Division of Family Health: Abortion: A tabulation of available data on the frequency and mortality of unsafe abortion. WHO/MCH/90. 14, 1990. WHO, Geneva. Armstrong, S. (1991): Female circumcision: fighting a cruel tradition. New Sci., 2 Feb. Schryver De, A. and Meheus, A. (1990): Epidemiology of sexually transmitted diseases: the global picture. Bull. W.H.O., 68, 639-654. World Health Organization (1990): World Health Organization, Division of Epidemiological Surveillance and Health Situation and Trend Assessment 1990. Global estimates for health situation assessment and projections. WHO/HST/90, 2. WHO, Geneva. World Health Organization (1991): The global HIV/AIDS situation. In Point of Fact No. 74. WHO, Geneva. World Health Organization (1986): World Health Organization, Division of Family Health 1986. Maternity Mortality Rates. A tabulation of available information, 2nd Edn. WHO, Geneva.
