Today we were visited again by Siri Tellier with a focus this time on Sexual and reproductive health and rights including family planning and abortion.

Before the lecture we were asked to read “Sexual and reproductive health and rights – in defence of life. Policy brief. 2012

We started off with some key definitions: (After Siri went on a mini rant about how much she hates definitions, but sometimes they are just necessary..)

1. Reproductive health: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore 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. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health reproducing health care is defined as the constellation of preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations and not merely counselling and care related to reproduction and sexually transmitted disease

(Source: international conference on population and development programme of action, ICPD PoA, 1994, Para 7.3)

1. Reproductive health: the complete physical, mental and social well-being related to the reproductive system throughout the life cycle
2. Reproductive rights: those are couples and individuals to freely and responsibly decide the timing, number and spacing of children, and to access information and care in all matters related to reproduction
3. Sexual health: a state of physical, mental and social well-being in relation to sexuality throughout the life cycyle
4. Sexual rights: includes the right to not be subjected to sexual violence and coercion, as well as to a safe and satisfying sex life – including the right to say “no” to sex

(Adapted from the ICPD Plan of Action)

2. Family planning: the basic right of all couples and individuals to decide freely and responsible the number, spacing and timing of their children and to have the information and means to do so. This definition builds on CEDAW (1979), and is seen to include both contraception and infertility treatment, but only ‘other means of fertility regulation which are not against the law’
   1. International consensus demographic goals: Governmental goals for family planning should be defined in terms of unmet needs for information and services; and demographic goals, while legitimately the subject of government development strategies, should not be imposed on family planning providers in the form of targets or quotas for the recruitment of clients
3. Abortion: a procedure for provoking termination of pregnancy, where pregnancy is taken to begin with the implantation of the foetus in the womb (sometimes also to stillbirth and miscarriage).
4. Unsafe abortion: A procedure carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

We briefly went back to the international consensus: Millennium development goals (2001/2008) looking at goal number 5

5. Improve Maternal Health
   1. Target 5.A: reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

• 5.1: Maternal mortality ratio
• 5.2: Proportion of births attended by skilled health personnel

5. • Target 5.B: Achieve, by 2015, universal access to reproductive health
   • 5.3: contraceptive prevalence
   • 5.4: Adolescent birth rate

• 5.5: Antenatal care coverage (at least one visit and at least four visits)

5. 5.6: Unmet need for family planning

• These goals seemed pretty realistic, although not met fully. Achieving these in many places is hard, with many different sets and types of challenges getting in the way. Many countries and villages (especially the smaller rural villages in developing countries) have issues with following anything like these goals. Rape and sexual abuse are seen every day in so many places with no punishment because many are too afraid to come or speak up about the incident. It is also commonly seen by military or persons with power, making it almost impossible to punish the act done. Women are too afraid to come in, and when they do go to a hospital they usually come in with “general body pain, feeling sick to their stomach, sore muscles, etc” and only after a full physical do the doctors know if the woman or even sometimes men were abused or raped.
• Many places as well do not have contraception still, or do not have it accessible to everyone. Contraception was illegal in many states until 1965-1967, now it is only illegal in one state – can you guess? (Not that there are any women there.. but..) Vatican state. Abortion is still illegal in a few places as well, making unsafe abortion a big problem in overall health.
• Another thing is the number of birth attendants to number of births is very far off. To give you an idea – 14% of births in Chad, 29% of births in Niger, 17% in South Sudan, and 20% in Sudan are attended by a skilled birth health personnel, which here in Canada, at least 99% of all births are attended by a skilled birth health personnel. Some of this is to do with the distance between the villages and hospitals or clinics, the use of traditional healers, and the use of traditional midwives (who are only trained by their mothers who were the selected village midwife). The main reason seems to be the availability of clinics and personnel as well as the distance between the mother and the clinics or hospitals. Infrastructure (like roads) aren’t accessible or even existing, cars aren’t used and who really would enjoy being in labour on a bicycle or motor bike going over gravel or mud roads on the way to give birth – no thanks.
• Looking at some numbers related we can see why these goals need to be pushed and put into effect
  • Maternal deaths – 289,000
  • Stillbirths directly caused by maternal disease and poor delivery care – 2.7 million
  • Early neonatal deaths – 2.8 million
    • We compared these numbers to the following: (please tell me you are as shocked as I was. But think about the news – what do we hear about, what do we not hear about, what is pushed through publicity and how often do you see these in the news or in commercials, etc… compared to the above)
  • All AIDS deaths per year – 1.5 million
  • All TB deaths per year – 1.1 million (+360,000 HIV+)
  • All malaria deaths per year – 472,000
    • Now think about the money we put into TB, HIV/AIDS and malaria, and all those disease we see in the news. The difference in overall numbers [Maternal/neonatal deaths and related – 5.789 million deaths per year] and [AIDS, TB, malaria deaths and related – 3.072 million deaths per year] is actually pretty shocking, why? Well I realized.. and I hope you do too.. I never see anything in the news about maternal, neonatal deaths, poor maternal health, stillbirths or anything really related to these in the news or in the commercials to raise funding, or publicity of charities working in these areas, etc.

“Are Women ‘Baby-Making Machines’?” – on Jan 27^th, Yanagisawa told his supporters in a speech touching on Japan’s low birthrate: “Because the number of birth-giving machines and devices is fixed, all we can ask for is for them to do their best per head”

• Yes, according to no less an expert than the health minister of Japan, Hakuo Yanagisawa made the comment recently as he addressed Japan’s low birthrate
• I find this comment almost.. but I’m not sure.. insulting? Apparently he didn’t mean it in an insulting way but it does come across as “women are things” – and apparently he had to retire after this comment – haha smooth…

Now we go into the components of SRHR (Sexual and Reproductive Health and Rights)

• International consensus – components of reproductive health CARE (source: WHO: reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Adopted by World Health Assembly 57^th session May 2004, p. 21)

1. Improving antenatal, delivery, postpartum and newborn care
2. Providing high quality services for family planning, including infertility services
   1. Methods include – contraception, abortion and infertility treatment
3. Eliminating unsafe abortion
4. Combating STIs, including HIV, cervical cancers and other gynaecological morbidities
5. Promoting sexual health

Contraceptives have increased in many regions and have much variation in method mix, some examples include:

• Traditional methods
  • Most commonly used method in Albania (2008-09)
• Other modern methods
• Male condom
  • Turkey had the highest used of condoms out of the numbers we were given but these numbers were still very low
  • Condoms seem to be the one of the least used ways of contraception – go figure.. but condoms are expensive and not covered by any medical coverage in so many places that if it is between food or condoms, food will win every time.
• Intrauterine device
  • Common in Egypt
• Injectable or implant
• Pill
  • Most common use in Germany, Morocco, and Zimbabwe
• Sterilisation
  • Very common in India

Although very effective, all methods have failure rates – in idea situations 6-8 million unwanted pregnancies

• Male condom 14% failure rate (users in 2000’s = 69884 / accidental pregnancies = 9784)
• Vaginal barrier 20% failure rate (users in 2000’s = 2291 / accidental pregnancies = 458)
• Periodic abstinence 25% failure rate (users in 2000’s = 37806 / accidental pregnancies = 9452)
• Even female and male sterilization have 0.15-0.5% failure rates (female more than male) – “shit happens” excuse my language but sometimes things don’t go right, there are many cases (especially in women) that the wrong ‘tubes’ get tied so they are still fertile but don’t practice with contraceptives because they think they are protected from pregnancy [even if they are you should still be using protection against STIs]. (users in 2000’s [f:m] = 232564:32078 / accidental pregnancies = 1163:48)

Infertility is defined as a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months of more to regular unprotected sexual intercourse

• About a quarter experience at some point in their lives

Pregnancies have higher risk of complications if they are early in life (younger than 15), closely spaced between births (antenatal and neonatal mortality could be decreased by 10-35% if parents used a minimum spacing of 2 years), the more babies the more risk (the 1^st baby and then any babies above 4 or 5 have an increase in risk of complications) as well as if they are unwanted or unplanned and an unsafe abortion may occur. About 90% of global abortion related and 20% of obstetric related mortality, leading to about 32% of maternal deaths could be avoided by contraception – mostly related to unsafe abortions. So if there is more family planning, education and contraceptive use, there will be less unwanted and unplanned pregnancies, leading to a decrease in need for unsafe abortions.

Abortion rate: the number of abortions for every 1000 women aged 15-44

Abortion is illegal for many reasons – including to save the life of the mother – in 5-6 countries, in the rest it is permitted under certain circumstances but it is not always readily accessible or available. Because of this, the number of unsafe abortions is still high because women still look for ways to abort an unwanted, unplanned or shameful (from rape or affair) pregnancy. Approx. 47,000 maternal deaths due to unsafe abortion per year. Safe abortions usually have very low complication rates – 0.6/100,000 procedures end in complications).

Global numbers:

Safe:                                               Unsafe:

• 1995: 46 million               – 20 million
• 2003: 42 million              – 19.7 million
• 2008: 44 million              – 21.6 million

For now this is all I will write about, the other lectures have not been posted for viewing yet. As soon as they get edited and photos of patients have been removed I will add on to this post more on sexual and reproductive health and family planning and abortions!

Tonight we had a party with everyone from the course invited! We had traditional (well I didn’t I had a very yummy salad and souvlaki because of my allergies) Danish food, welcomed by a very interesting alcoholic drink on the house and very enjoyable conversation. After eating we got into teams – I was on the blue team, we made our team name “The Smurfs” and we played a few quizzes. Ahem.. my team won! We got free drinks. There was music, dancing, limbo and many drinking games like Meyer and beer pong with the professors and organizers – what a great party! Sadly I left early due to some personal reasons so I missed out on the pub crawl afterwards, apparently the party went on till about 4 or 5 am.

Saturday and Sunday, I explored Copenhagen! My first full days of freedom to explore and see the wonderful things offered here. I joined a few friends on a free walking tour around the city, we saw so much within the few hours of the tour and did a total of 6 hours walking without sitting down – my feet were sooooo sore! We saw many small places you would never really see – where Han Christian Anderson (the fairytale writer) was born, where he worked, where he lived, the opera house and theater where he tried to be a ballet dancer, then an actor and an opera singer – where his angelic voice was discovered at 14 years of age until he matured and his voice dropped. We saw the Carlsberg house (famous beer here in Denmark), and a few cute little streets where the houses are all painted beautiful colours. We went to the harbour. Again went to the Palace and Queen’s gardens. So many things to see here! I have a list on my phone of all the things I want to do and see here so hopefully I will get to do that and share that with you! I will try to take as many photos as I can 🙂

      (military ship in the harbour)  (one of the biggest attractions in the Copenhagen.. the little mermaid!)