What is new about the concept of reproductive health

Reproductive health does not start out from a list of diseasesor problems - sexually transmitted diseases, maternal mortality or from a list of programmes - maternal and child health, safemotherhood, family planning.  Reproductive health instead must beunderstood in the context of relationships: fulfilment and risk; the opportunity to have a desired child þ or alternatively, to avoid unwanted or unsafe pregnancy.Reproductive health contributes enormously to physical and psychosocial comfort and closeness, and to personal and social maturation þ poor reproductive health is frequently associated with disease, abuse, exploitation, unwanted pregnancy, and death.The most significant achievement of the Cairo Conference was to place people firmly at the centre of development efforts, as protagonists in their own reproductive health and lives rather than as objects of external interventions.The aim of interventions is to enhance reproductive health and promote reproductive rights rather than population policies and fertility control.  This implies the empowerment of women (including through better access to education;the involvement of women and young people in the development and implementation of programmes and services; reaching out to the poor, the marginalized and the excluded; and assuming greater responsibility for reproductive health on the part of men. How this concept of reproductive health differs from exist in family planning and maternal and child health programmes Programmes dealing with various components of reproductive health exist in some form almost everywhere. But they have usually been delivered in a separate way, unconnected to programmes dealing with closely interdependent topics. For example, the objectives,design and evaluation of family planning programmes were largely driven by a demographic imperative, without due consideration to related health issues such as maternal health or STD prevention and management.Evaluation was largely in terms of quantity rather than quality - numbers of contraceptive acceptors as opposed to the ability and opportunity to make informed decisions about reproductive health issues.  In general, such programmes exclusively targeted women, taking little account of the social, cultural and intimate realities of their reproductive lives and decision-making powers.  They tended to serve only married people, designed to serve men even though they have reproductive health excluding, in particular, young people.  Services were rarely concerns of their own, particularly with regard to sexually transmitted diseases.Moreover, the involvement of men in reproductive health is important because they have an important role to play as family decision-makers with regard to family size, family planning and use of health services.A reproductive health approach would differ from a narrow family planning approach in several ways.  It would aim to build upon what exists and at the same time to modify current narrow,vertical programmes to ones in which every opportunity is taken to offer women and men a full range of reproductive health services in a linked way.  The underlying assumption is that people with a need in one particular area - say treatment of a sexually transmitted diseases - also have needs in other areas - family planning or antenatal/postpartum care.  Such programmes would recognize that dealing with one aspect of reproductive health can have synergistic effects in dealing with others.  For example, management of infertility is difficult and expensive but it can be largely prevented through appropriate care during and after delivery and prevention and management of STDs.  Promotion of breast-feeding has an impact on reproductive health in many ways - it helps prevent certain postpartum problems, delays the return to fertility, may help prevent ovarian and breast cancer, and improves neonatal health. Another important difference between existing programmes and those developed to respond to the new concept of reproductive health is the way in which people - particularly women and young people who are the most affected by reproductive health concerns - are involved in programme development, implementation and evaluation. When women become more involved in programmes it becomes clearer that they have health concerns beyond motherhood and also that dealing with reproductive health involves a profound rethinking of the behavioural, social, gender and cultural dimensions of decision-making which affect women's reproductive lives.
What reproductive health services includes 
The precise configuration of reproductive health needs and concerns, and the programmes and policies to address them, will vary from country to country and will depend on an assessment of each country's situation and the availability of appropriate interventions. Globally, however, both the epidemiological data and the expressed wishes of diverse constituencies indicate that reproductive health interventions are most likely to include attention to the issues of family planning, STD prevention and management and prevention of maternal and perinatal mortality and morbidity.  Reproductive health should also address issues such as harmful practices, unwanted pregnancy, unsafe abortion, reproductive tract infections including sexually transmitted diseases and HIV/AIDS, gender-based violence, infertility,malnutrition and anaemia, and reproductive tract cancers. Appropriate services must be accessible and include information, education, counselling,  prevention, detection and management of health problems, care and rehabilitation.  Reproductive health strategies should be founded first and foremost on the health of individuals and families.  In the operationalization of the strategies all reproductive health services must assume their responsibility to offer accessible and quality care, while ensuring respect for the individual, freedom of choice, informed consent, confidentiality and privacy in all reproductive matters.  They should focus special attention on meeting the reproductive health needs of adolescents.
   Factors affecting reproductive health
   Reproductive health affects, and is affected by, the broader context of people's lives, including their economic circumstances, education, employment, living conditions and family environment, social and gender relationships, and the traditional and legal structures within which they live.  Sexual and reproductive behaviours 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.     The status of girls and women in society, and how they are treated or mistreated, is a crucial determinant of their reproductive health. Educational opportunities for girls and women powerfully affect their status and the control they have over their own lives and their health and fertility. The empowerment of women is therefore an essential element for health. 
Who is most affected by reproductive health problems 
Women bear by far the greatest burden of reproductive health problems. Women are at risk of complications from pregnancy and childbirth; they also face risks in preventing unwanted pregnancy, suffer the complications of unsafe abortion, bear most of the burden of contraception, and are more exposed to contracting, and suffering the complications of reproductive tract infections, particularly sexually transmitted diseases (STDs). Among women of reproductive age, 36% of all healthy years of life lost is due to reproductive health problems such as unregulated fertility, maternal mortality and morbidity and sexually transmitted diseases including HIV/AIDS.  By contrast, the equivalent figure for men is 12%.  Biological factors alone do not explain women's disparate burden. Their social, economic and political disadvantages have a detrimental impact on their reproductive health. Young people of both sexes, are also particularly vulnerable to reproductive health problems because of a lack of information and access to services.     How countries can identify reproductive health needs and assess priorities     A number of countries have expressed the desire to move forward with a new and comprehensive approach to reproductive health.  Support to national authorities in carrying out a systematic review of reproductive health needs at country level should focus on the importance of adding innovative and participatory approaches to more familiar epidemiological methodologies in which the process tends to be directed by experts and framed by biomedical approaches and indicators.  The identification of reproductive health needs, the determination of priorities and the development of programmatic responses to those needs should be conducted through an inclusive process, soliciting the perspectives of a range of groups concerned with reproductive health including, for example, women's health advocates, youth groups, health care providers at the periphery as well as at the central level, health planners, researchers, and non-governmental organizations.       Several instruments have already been developed for situationanalysis and needs assessment in different components of reproductive health, for example, family planning and safe motherhood.  However, in the context of the new approach to reproductive health it is necessary to ensure that assessment and prioritization reflect people's concerns as agreed at national and local levels and not the priorities of agencies or donors.  It is important to avoid duplication and to develop tools that are appropriate for countries themselves.  A number of such instruments already exist and are widely used.  However, it is important to ensure compatibility and consistency among the various instruments currently available.     Similar considerations apply to the selection of priorities for action in reproductive health.  Criteria for identification of priority problems should include not only importance - prevalence, severity, public concern, government commitment, impact on family, community and development - but also the feasibility of addressing them - known interventions, cost-effectiveness, availability of financing, human resources and adequate equipment and supplies.    
Human resources for reproductive health     
The operationalization of the new concept of reproductive health will mean changes in skills, knowledge, attitudes and management.  People will have to work together in new ways.  Health care providers will have to collaborate with others, including NGOs, women's health advocates, and young people.  Managerial and administrative changes will also be needed because integrated services can impose, at least initially, greater burdens on already over-stretched staff and require attention to planning and logistics in order to ensure availability and continuity of services.     Training for reproductive health workers will need to focus on improving both technical and interpersonal skills.  Additional training, particularly in counselling skills and in ways of reaching out to under-served groups will be essential elements of such training.  The back-up and support of functioning referral systems will be essential elements if the full range of reproductive health concerns is to be adequately addressed.